|
<br />
<br />Exhibit C -- Fage 2
<br />Expenses Related to Volume, but not inclusive to all available lab tests.
<br />Laboratorv Tests
<br />CPT Code Descr~tion Cost ep r Test
<br />80101 Drug Profile $ 19.00
<br />87880 Rapid Strep Test $ 4.00
<br />87804 Influenza Test $ 12.00
<br />81000 Urinalysis, Dip Stick , $ 2.00
<br />80061 Lipid Panel _:::~ ~ x:.12.00
<br />80048 Basic metabolic panel ,~~~ $ ~'S.00
<br />81001 Urinalysis, Cult., if infected,, .. ~=r~;; , $ 8.00
<br />8IU03 Urinalysis ` ~~~ .~." 8.00
<br />80076 Hepatic Function Paned==:•r ' ~ `'`~,SQ
<br />86757 Rocky Mtn Spott.Fe~~r ICi~/IGM $ d'~;~Q
<br />86617 Lyme Disease, V~~~~Blot Blood $ 42.9Q ,:,, _.;
<br />80053 Comprehensive~~vl8f~bglic Peel $ 10.00 "'.'
<br />85025 CBC w Dill '~ ~ ` : ?~ ~ ~ $ 5.00`'
<br />85044 Reticuloeyte count ~ `~~ ,, $ 10A0
<br />rf,=t,
<br />87491 Chlamyc~j~,~,,~-MP DNA (Piro~~~ec) $ 21.50
<br />87591 GC, Ampl~i~ird,•DAN (Probetee} ~ ::; _; ~t $ 21.50
<br />87210 Wetmourifi<; '~ •~:;.°~'~ f~ ~ $ 7.50
<br />~~"`` e '' $ 10.00
<br />84443 Thyroid Stii~~tlati~~ ~ l~~p ; ~~~
<br />r~- :h..=
<br />84439 . _~.~ ~.~~4, Free (Th}~~lne) ~~~~:3' $ 20.00
<br />,.~ •~....., Y
<br />8303~,;~` ~ ~I-~~~xlnoglobin,,A'C ~ $10A0
<br />82~'lU~~,;, O~e~c'ult Blood, Sttt,~l ~3 pack) $17.40
<br />82272 ~'<_~ : O~~uI(,Blood, Stb~(;f (single) $ 17.40
<br />~.1- 1: ~_~..__
<br />52 ": `~": }_" 4.00
<br />• ~~g6~:08. ~=~Ilii,Heterople~(Mono Test) $ 6.00
<br />~~~ 82947 ~~ .~.~~-. C31u~ey,,~ingerstick $ 4.00
<br />,- 86677 ~''s; ~: Heil~a~~cter pylori AB, Qual $ 13.5Q
<br />;:.. 86592 `''~''~ Syp}~tlis test (RPR) $ 7.80
<br />"'~$2,~043 _, ~ Microalbumin, urine, quant $ 20.00
<br />''$~5:'~0 ~,;~ Creatinine, urine, spot $ 5.00
<br /><., .
<br />867~':~., .._~~t~ Mumps Antibody IGM $ 34.20
<br />8252~~:"~; ~ N-Telopeptide Crosslink, Urine $ 45.90
<br />8717~~ Ova & Parasites $ 46.52
<br />80185 Phenytoin (Dilantin) $ 10.40
<br />87172 Pinworm Exam $ 4.00
<br />81025 Pregnancy test, Urine $ 9.00
<br />84703 Pregnancy test, Serum $ 9.OQ
<br />84153 Prostate Specific Antigen, PSA $ 15.00
<br />83970 PTH, In#act $ 25.00
<br />82607 Vitamin B12 Level $ 5.00
<br />82746 Folic Acid (Folate}, Serum $ 10.00
<br />86703 HN 1,2 Antibody Screen $ 30.00
<br />85018 Hemoglobin, fingerstick $ 4.OQ
<br />Attachment number 1
<br />F_8 Page 246 of 433 '
<br />
|