HUMAN CHORIONIC GONADOTROPHIN
human chorionic gonadotrophin 1500 units injection [3 vials] (&) inert substance diluent
[3 x 1 mL vials], 1 pack
Manner of administration:Injection
Restriction (Streamlined authority code: 6991)
Indication: Assisted Reproductive Technology
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 1 | Max qty units: 1 | # of repeats: 0 | DPMQ: $154.40 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Brevactid 1500 I.E | |||||
human chorionic gonadotrophin 1500 units injection [3 vials] (&) inert substance diluent
[3 x 1 mL vials], 1 pack
Manner of administration:Injection
Restriction
Indication: Anovulatory infertility
Restriction
Indication: Infertility
Restriction
Indication: Infertility
Restriction
Indication: Combined deficiency of human growth hormone and gonadotrophins
Restriction
Indication: Hypogonadism or delayed puberty
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 1 | Max qty units: 1 | # of repeats: 5 | DPMQ: $166.75 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Brevactid 1500 I.E | |||||
human chorionic gonadotrophin 5000 units injection [1 vial] (&) inert substance diluent
[1 mL syringe], 1 pack
Manner of administration:Injection
Restriction (Streamlined authority code: 6991)
Indication: Assisted Reproductive Technology
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 2 | Max qty units: 2 | # of repeats: 0 | DPMQ: $226.94 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Choriomon 5000 I.E | |||||