| Code | Description | States | Median rate |
|---|---|---|---|
| Q0035 | Cardiokymography | 17 | $17.55 |
| Q0091 | Screening papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory | 21 | $32.42 |
| Q0092 | Set-up portable x-ray equipment | 21 | $17.09 |
| Q0111 | Wet mounts, including preparations of vaginal, cervical or skin specimens | 39 | $14.37 |
| Q0112 | All potassium hydroxide (koh) preparations | 39 | $5.09 |
| Q0113 | Pinworm examinations | 33 | $4.21 |
| Q0114 | Fern test | 32 | $8.77 |
| Q0115 | Post-coital direct, qualitative examinations of vaginal or cervical mucous | 23 | $20.00 |
| Q0138 | Injection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg (non-esrd use) | 33 | $0.37 |
| Q0139 | Injection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg (for esrd on dialysis) | 26 | $0.37 |
| Q0144 | Azithromycin dihydrate, oral, capsules/powder, 1 gram | 12 | $14.53 |
| Q0161 | Chlorpromazine hydrochloride, 5 mg, oral, fda approved prescription anti-emetic, for use as a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen | 12 | $0.35 |
| Q0162 | Ondansetron 1 mg, oral, fda approved prescription anti-emetic, for use as a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen | 19 | $0.01 |
| Q0163 | Diphenhydramine hydrochloride, 50 mg, oral, fda approved prescription anti-emetic, for use as a complete therapeutic substitute for an iv anti-emetic at time of chemotherapy treatment not to exceed a 48 hour dosage regimen | 15 | $0.19 |
| Q0164 | Prochlorperazine maleate, 5 mg, oral, fda approved prescription anti-emetic, for use as a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen | 17 | $0.35 |
| Q0166 | Granisetron hydrochloride, 1 mg, oral, fda approved prescription anti-emetic, for use as a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 24 hour dosage regimen | 21 | $1.51 |
| Q0167 | Dronabinol, 2.5 mg, oral, fda approved prescription anti-emetic, for use as a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen | 19 | $1.86 |
| Q0169 | Promethazine hydrochloride, 12.5 mg, oral, fda approved prescription anti-emetic, for use as a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen | 17 | $0.05 |
| Q0173 | Trimethobenzamide hydrochloride, 250 mg, oral, fda approved prescription anti-emetic, for use as a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen | 12 | $0.84 |
| Q0175 | Perphenazine, 4 mg, oral, fda approved prescription anti-emetic, for use as a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen | 15 | $0.51 |
| Q0177 | Hydroxyzine pamoate, 25 mg, oral, fda approved prescription anti-emetic, for use as a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen | 14 | $0.05 |
| Q0180 | Dolasetron mesylate, 100 mg, oral, fda approved prescription anti-emetic, for use as a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 24 hour dosage regimen | 17 | $66.71 |
| Q0224 | Injection, pemivibart, for the pre-exposure prophylaxis only, for certain adults and adolescents (12 years of age and older weighing at least 40 kg) with no known sars-cov-2 exposure, and who either have moderate-to-severe immune compromise due to a medical condition or receipt of immunosuppressive medications or treatments, and are unlikely to mount an adequate immune response to covid-19 vaccination, 4500 mg | 16 | $7,239.00 |
| Q0249 | Injection, tocilizumab, for hospitalized adults and pediatric patients (2 years of age and older) with covid-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ecmo) only, 1 mg | 19 | $7.38 |
| Q0477 | Power module patient cable for use with electric or electric/pneumatic ventricular assist device, replacement only | 17 | $781.56 |
| Q0478 | Power adapter for use with electric or electric/pneumatic ventricular assist device, vehicle type | 12 | $190.83 |
| Q0479 | Power module for use with electric or electric/pneumatic ventricular assist device, replacement only | 12 | $12,432.66 |
| Q0480 | Driver for use with pneumatic ventricular assist device, replacement only | 12 | $92,127.83 |
| Q0481 | Microprocessor control unit for use with electric ventricular assist device, replacement only | 12 | $14,863.73 |
| Q0482 | Microprocessor control unit for use with electric/pneumatic combination ventricular assist device, replacement only | 12 | $4,655.60 |
| Q0483 | Monitor/display module for use with electric ventricular assist device, replacement only | 12 | $19,179.02 |
| Q0484 | Monitor/display module for use with electric or electric/pneumatic ventricular assist device, replacement only | 12 | $3,724.51 |
| Q0485 | Monitor control cable for use with electric ventricular assist device, replacement only | 12 | $359.57 |
| Q0486 | Monitor control cable for use with electric/pneumatic ventricular assist device, replacement only | 12 | $299.30 |
| Q0487 | Leads (pneumatic/electrical) for use with any type electric/pneumatic ventricular assist device, replacement only | 13 | $354.46 |
| Q0489 | Power pack base for use with electric/pneumatic ventricular assist device, replacement only | 13 | $16,878.82 |
| Q0490 | Emergency power source for use with electric ventricular assist device, replacement only | 12 | $787.57 |
| Q0491 | Emergency power source for use with electric/pneumatic ventricular assist device, replacement only | 12 | $1,238.14 |
| Q0492 | Emergency power supply cable for use with electric ventricular assist device, replacement only | 12 | $99.74 |
| Q0493 | Emergency power supply cable for use with electric/pneumatic ventricular assist device, replacement only | 12 | $284.05 |
| Q0494 | Emergency hand pump for use with electric or electric/pneumatic ventricular assist device, replacement only | 12 | $240.37 |
| Q0495 | Battery/power pack charger for use with electric or electric/pneumatic ventricular assist device, replacement only | 12 | $4,678.79 |
| Q0496 | Battery, other than lithium-ion, for use with electric or electric/pneumatic ventricular assist device, replacement only | 14 | $1,556.77 |
| Q0497 | Battery clips for use with electric or electric/pneumatic ventricular assist device, replacement only | 12 | $524.38 |
| Q0498 | Holster for use with electric or electric/pneumatic ventricular assist device, replacement only | 12 | $575.38 |
| Q0499 | Belt/vest/bag for use to carry external peripheral components of any type ventricular assist device, replacement only | 12 | $186.94 |
| Q0500 | Filters for use with electric or electric/pneumatic ventricular assist device, replacement only | 12 | $34.22 |
| Q0501 | Shower cover for use with electric or electric/pneumatic ventricular assist device, replacement only | 10 | $572.02 |
| Q0502 | Mobility cart for pneumatic ventricular assist device, replacement only | 10 | $728.26 |
| Q0503 | Battery for pneumatic ventricular assist device, replacement only, each | 12 | $1,456.57 |
| Q0504 | Power adapter for pneumatic ventricular assist device, replacement only, vehicle type | 12 | $768.60 |
| Q0506 | Battery, lithium-ion, for use with electric or electric/pneumatic ventricular assist device, replacement only | 13 | $1,026.54 |
Published Medicaid fee-for-service schedule amounts, not a coverage or eligibility guarantee. Managed-care plan rates can differ. Where no prior-authorization flag is shown, the state does not publish one. Descriptions are ProviderSignal's own plain-language labels or public-domain CMS text.