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Hydroxyzine Pamoate, Oral

Wisconsin rates for HCPCS Q0177

Hydroxyzine pamoate, 25 mg, oral, FDA-approved prescription antiemetic, for use as a complete therapeutic substitute for an IV antiemetic at the time of chemotherapy treatment, not to exceed a 48-hour dosage regimen

Rates data updated July 2026.

Facilitymedian $0 · 10th–90th $0$30%20%10th90th$0Professionalmedian $0 · 10th–90th $0$40%20%10th90th$0$0.1$0.2$1.0$5.0$20.0$100.0

Distribution of negotiated rates across all payers (price axis is log-scale). Facility and professional rates are different services and are charted separately. Need provider-level prices? Contact us.

Insurance Carrier
Aetna
Setting
Facility
Modifier
Global
Typical Low
$0.12
Median
$0.12
Typical High
$4.17
Aetna
Setting
Professional
Modifier
Global
Typical Low
$0.12
Median
$0.12
Typical High
$0.15
Anthem BCBS
Setting
Professional
Modifier
Global
Typical Low
$0.13
Median
$0.13
Typical High
$5.62
CareSource
Setting
Facility
Modifier
Global
Typical Low
$1.48
Median
$2.00
Typical High
$3.24
CareSource
Setting
Professional
Modifier
Global
Typical Low
$1.70
Median
$1.78
Typical High
$2.63
Cigna
Setting
Facility
Modifier
Global
Typical Low
$0.17
Median
$1.02
Typical High
$1.70
Cigna
Setting
Professional
Modifier
Global
Typical Low
$0.13
Median
$0.42
Typical High
$3.89
DeanCare
Setting
Facility
Modifier
Global
Typical Low
$0.12
Median
$0.13
Typical High
$2.00
DeanCare
Setting
Professional
Modifier
Global
Typical Low
$0.26
Median
$0.26
Typical High
$0.26
Medica
Setting
Facility
Modifier
Global
Typical Low
$0.10
Median
$0.12
Typical High
$3.98
Medica
Setting
Professional
Modifier
Global
Typical Low
$0.10
Median
$0.10
Typical High
$61.66
Molina
Setting
Professional
Modifier
Global
Typical Low
$0.04
Median
$50.12
Typical High
$70.79
Network Health
Setting
Facility
Modifier
Global
Typical Low
$2.09
Median
$2.09
Typical High
$2.09
Network Health
Setting
Professional
Modifier
Global
Typical Low
$2.45
Median
$2.45
Typical High
$2.95
Prevea360
Setting
Facility
Modifier
Global
Typical Low
$0.12
Median
$0.13
Typical High
$2.00
Prevea360
Setting
Professional
Modifier
Global
Typical Low
$0.26
Median
$0.26
Typical High
$0.26
Quartz
Setting
Professional
Modifier
Global
Typical Low
$2.24
Median
$4.37
Typical High
$6.61
Quartz
Setting
Facility
Modifier
Global
Typical Low
$0.15
Median
$85.11
Typical High
$100.00
Quartz
Setting
Professional
Modifier
Global
Typical Low
$0.13
Median
$0.16
Typical High
$61.66
Security Health
Setting
Professional
Modifier
Global
Typical Low
$3.02
Median
$3.02
Typical High
$3.80
United
Setting
Facility
Modifier
Global
Typical Low
$0.15
Median
$2.00
Typical High
$4.68
United
Setting
Professional
Modifier
Global
Typical Low
$0.13
Median
$0.13
Typical High
$0.15