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Washington rates for HCPCS J7643

Glycopyrrolate, inhalation solution, compounded product, administered through DME, unit dose form, per mg

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.13 / $1.78 / $1.78
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.74 / $0.76 / $0.89
Asuris Northwest Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$95.00 / $95.00 / $100.00
Asuris Northwest Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.76 / $1.26 / $50.00
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.76 / $0.76 / $3.04
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.76 / $0.76 / $0.76
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.95 / $1.06 / $2.12
Pacific Source
Facility/Professional
Facility
Modifier
Low / Median / High Price
$79,999.20 / $79,999.20 / $79,999.20
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.09 / $0.09 / $0.09
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.76 / $0.89 / $0.89
Wellpoint
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.76 / $0.76 / $0.76