Thomas Jefferson University Department of , and Cel Biology Professional Fees

Name______

Institution/Location______

Department______

City ______

State______Zip Code______

Contact Number______

Email Address______

Departmental Charge Code ______/ ______/ ______/ ______

Number of SamplesFee Per Sample Total Fees Level I – , gross examination only ______$6.02 $______Level I – Surgical pathology, gross examination only ______$32.59 $______Level II– Surgical pathology, gross and microscopic ______$8.87 $______Level II– Surgical pathology, gross and microscopic examination ______$68.10 $______Level III– Surgical pathology, gross and microscopic examination ______$14.60 $______Level III– Surgical pathology, gross and microscopic examination ______$85.99 $______Level IV– Surgical pathology, gross and microscopic examination ______$50.07 $______Level IV– Surgical pathology, gross and microscopic examination ______$144.73 $______Level V– Surgical pathology, gross and microscopic examination ______$106.41 $______Level V– Surgical pathology, gross and microscopic examination ______$288.64 $______Level VI – Surgical pathology, gross and microscopic examination ______$182.37 $______Level VI – Surgical pathology, gross and microscopic examination ______$431.46 $______Decalcification ______$16.05 $______Decalcification ______$24.91 $______Special Stain, Group I ______$35.43 $______Special Stain, Group I ______$135.95 $______Special Stain, Group 2 ______$15.55 $______Special Stain, Group 2 ______$89.37 $______Consultation and report on referred slides ______$105.51 $______Consultation and report on referred slides ______$117.66 $______Consultation and report on referred material ______$113.88 $______Consultation and report on referred material ______$193.36 $______Frozen section(s) ______$80.08 $______Frozen section(s) ______$122.05 $______Additional tissue block with frozen section(s) ______$39.30 $______Additional tissue block with frozen section(s) ______$54.46 $______Touch prep, Squash prep), initial site ______$80.04 $______Touch prep, Squash prep), initial site ______$125.06 $______Touch prep, Squash prep), initial site ______$47.88 $______Touch prep, Squash prep), initial site ______$75.21 $______Immunohistochemistry (including tissue immunoperoxidase), each antibody ______$55.27 $______Immunohistochemistry (including tissue immunoperoxidase), each antibody ______$135.77 $______Immunofluorescent study, each antibody; direct method ______$56.26 $______Immunofluorescent study, each antibody; direct method ______$136.24 $______Electron microscopy; diagnostic ______$99.61 $______Electron microscopy; diagnostic ______$864.49 $______Morphometric analysis; manual ______$72.78 $______Morphometric analysis; manual ______$164.43 $______Morphometric analysis; computer assisted ______$79.53 $______Morphometric analysis; computer assisted ______$210.85 $______Nerve teasing ______$142.94 $______Nerve Teasing ______$359.62 $______In situ hybridization (eg, FISH), each probe ______$76.76 $______In situ hybridization (eg, FISH), each probe ______$213.47 $______Morphometric analysis, in situ hybridization (quantitative or semiquantitative), each probe; using computer- ______$83.17 $______Morphometric analysis, in situ hybridization (quantitative or semiquantitative), each probe; using computer- ______$331.25 $______Morphometric analysis, in situ hybridization (quantitative or semiquantitative), each probe; manual ______$87.36 $______Morphometric analysis, in situ hybridization (quantitative or semiquantitative), each probe; manual ______$290.87 $______Microdissectrion; laser capture ______$103.72 $______Microdissectrion; laser capture ______$270.49 $______Microdissection; manual ______$79.07 $______Microdissection; manual ______$294.78 $______

Total to be Charged to Department Charge Code $______

For Further Information Please Contact: Director Dr. Charalambos Solomides 215-503-6202 [email protected]

***Please drop all samples off at ______***

PI Signature______Date______

Administrator Signature______Date______