ALS BLOOD LAB REQUISITION SIMULATION ABC LAB REQUISITION SIMULATION PATIENT NAME: Reason for order: ICD10: ORDERING PHYSICIAN/INTERN (print): ADD Term: DOB: NPI/MATRIC: TEST NAME CODE COST Antipancreatic Islet Cells P160721 $59.00 Best Value Panel - New P365422 $229.00 C-Reactive Protein (CRP) High Sensitivity (Cardiac) P120766 $19.00 Cholesterol, Total P1065 $5.00 Complete Blood Count (CBC) With Differential and Platelet Count P5009 $10.00 Comprehensive Metabolic Panel P322000 $15.00 Rheumatoid Arthritis (RA) Expanded Profile P337791 $79.00 Gluconse and Hemoglobin A1c P25239 $21.00 Hepatic Function Panel P322755 $15.00 HIV 1/2 Antibody, Differentiation P83904 $65.00 HLA B 27 Disease Association P6924 $59.00 Human Immunodeficiency Virus 1/O/2 (HIV-1/O/2) Antigen/Antibody (Fourth P83935 Generation)$29.00 Preliminary Test W Lead Standard Profile, Blood P38170 $69.00 Lead Standard Profile, Pediatric P717035 $69.00 Lipid Panel (Compliance) P303756 $20.00 Lipid Panel with LDL/HDL Ratio P235010 $15.00 Lipid Panel With Total Cholesterol/HDL Ratio P221010 $15.00 Opti-ThyroPlex Panel II P237359 $265.00 Pancreatic Amylase, Serum P123111 $46.00 Pancreatic Cancer Monitor Profile P485086 $79.00 Sedimentation Rate (ESR), Westergren P5215 $12.00 Sexually Transmitted Infection (STI) Panel P240964 $159.00 T & B Lymphocyte / Natural Killer Cell (CD56) Panel with CBC and Differential P505370 with Platelet $139.00 Count Thyroid Comprehensive Panel I P333757 $119.00 Thyroid Comprehensive Panel II P333417 $125.00 Vitamin D, 1,25-Hydroxycalciferol (Calcitriol) and Vitamin D, 25-Hydroxy P80325 $67.00 Vitamin D, 25-Hydroxycalciferol P81950 $29.00 Total cost $