BOTULINUM TOXIN TYPE A
Manner of administration:Injection
Restriction (Streamlined authority code: 5409)
Indication: Urinary incontinence
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 4 | Max qty units: 4 | # of repeats: 0 | DPMQ: $1,098.88 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Botox | |||||
Manner of administration:Injection
Restriction (Streamlined authority code: 5221)
Indication: Blepharospasm or hemifacial spasm
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 4 | Max qty units: 4 | # of repeats: 0 | DPMQ: $1,098.88 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Botox | |||||
Manner of administration:Injection
Restriction (Streamlined authority code: 5359)
Indication: Dynamic equinus foot deformity
Restriction (Streamlined authority code: 8822)
Indication: Dynamic equinus foot deformity
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 4 | Max qty units: 4 | # of repeats: 0 | DPMQ: $1,098.88 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Botox | |||||
Manner of administration:Injection
Restriction (Streamlined authority code: 5178)
Indication: Moderate to severe spasticity of the upper limb
Restriction (Streamlined authority code: 8929)
Indication: Moderate to severe spasticity of the upper limb
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 4 | Max qty units: 4 | # of repeats: 0 | DPMQ: $1,098.88 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Botox | |||||
Manner of administration:Injection
Restriction (Streamlined authority code: 11784)
Indication: Chronic migraine
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 4 | Max qty units: 4 | # of repeats: 0 | DPMQ: $1,098.88 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Botox | |||||
Manner of administration:Injection
Restriction (Streamlined authority code: 6953)
Indication: Urinary incontinence
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 4 | Max qty units: 4 | # of repeats: 0 | DPMQ: $1,098.88 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Botox | |||||
Manner of administration:Injection
Restriction (Streamlined authority code: 18524)
Indication: Severe primary axillary hyperhidrosis
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 4 | Max qty units: 4 | # of repeats: 0 | DPMQ: $1,098.88 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Botox | |||||
Manner of administration:Injection
Restriction (Streamlined authority code: 5406)
Indication: Spasmodic torticollis
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 4 | Max qty units: 4 | # of repeats: 0 | DPMQ: $1,098.88 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Botox | |||||
Manner of administration:Injection
Restriction (Streamlined authority code: 9334)
Indication: Moderate to severe spasticity of the lower limb following an acute event
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 4 | Max qty units: 4 | # of repeats: 0 | DPMQ: $1,098.88 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Botox | |||||
Manner of administration:Injection
Restriction (Streamlined authority code: 9547)
Indication: Moderate to severe spasticity of the upper limb following an acute event
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 4 | Max qty units: 4 | # of repeats: 0 | DPMQ: $1,098.88 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Botox | |||||