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Contract : 5753 Vendor : Quest Diagnostics Description Contract : 5753 Vendor : Quest Diagnostics Pricing for frequently ordered tests is provided below. For all other tests not listed below, Contractor will provide a 65% discount off of their fee schedule. Contractors Fee Schedule is provided in Exhibit C. For any tests that appear in both the Frequently Ordered Tests List and the Fee Schedule, the pricing provided in the Frequently Ordered Tests List will prevail. Frequently Ordered Tests Description Code Unite Price Time Cholesterol 6165 $3.75 24hr Comprehensive Metabolic Panel w/eGFR 944 $6.43 24hr Chlamydia/GC DNA Amplified 17618 $49.10 24hr Drug Screen 7 Panel 800 $8.24 3-5 days Drug Screen 9 Panel 822 $9.46 3-5 days Drug Screen 10 Panel 821 $10.11 3-5 days Hepatitis B Surface Antibody Quantitative 7292 $9.75 24hr Hepatitis C Antibody 1590 $11.33 24hr Hepatic Function Panel 104 $4.93 24hr HIV 1/2 EIA Antibody with Reflexes 3200 $8.68 24hr HPV DNA (High Risk) 110814 $33.48 24hr Herpes Simplex Type 2 lgG, HerpeSelect 100051 $24.44 24hr Lipid Panel 1383 $12.10 24hr Pap, ThinPrep, No RESCRN 10090 $20.00 5 days Pap, ThinPrep, RESCRN 1090 $20.00 5 days Triglycerides 6440 $3.75 24hr TSH, 3rd Generation 7580 $11.75 24hr Urine Culture 2400 $8.43 24hr Varicella-Zoster lgG 123112 $18.00 6 days Surgical pathology, gross and microscpic exam Level IV AC03 $64.43 24-48 hr profile 47 47 $26.54 24hr Nicotine Urine 6224 6224 $25.50 5 days Hepatitis CaB 1590 1590 $11.33 24hr QuantiFERON-TB 4399 $43.35 5 days 8 Panel Drug Screen 819 $8.87 3-5 days Pregnancy, Urine 4723 $8.60 24hr PTT 4023 $4.50 24hr Culture, Wound 2275 $21.00 varies Valproic Acid 7590 $12.00 24hr Vit D, 25 Hydroxy 17306 $58.00 9 days Gram Stain 2025 $5.00 24hr Culture, Aerobic 2300 $16.00 varies Protime + INR 4021 $5.00 24hr Prothrombin Time 111126 $5.00 4 days EBV-VCA IGG AB 140465 $18.25 4 days T3 Free 1430 $5.62 24hr EBV AB IGM 151599 $18.25 4 days Contract : 5753 Vendor : Quest Diagnostics Pricing for frequently ordered tests is provided below. For all other tests not listed below, Contractor will provide a 65% discount off of their fee schedule. Contractors Fee Schedule is provided in Exhibit C. For any tests that appear in both the Frequently Ordered Tests List and the Fee Schedule, the pricing provided in the Frequently Ordered Tests List will prevail. Frequently Ordered Tests Description Code Unite Price Time Tissue Transglutam IGA 1549 $68.00 4 days RA Diagnostic Panel 17669 $102.82 3 days Group A Strep Rapid Scn 2031 $7.50 TBD Strep Scn Group A 2032 $7.50 TBD Group A Strep No Rfx 2034 $7.50 TBD CMV AB Profile 3100 $45.50 24hr CMV IGG AB 3105 $13.00 24hr HIV- 1 WB W/RFX HIV-2 3214 $42.39 TBD Heterophile, Mono Scn 4317 $18.25 24hr Sed Rate Westergren 4542 $4.21 24hr HIV-1 AB West Blot 5233 $42.39 TBD Lithium 6315 $9.83 24hr HCG, Total, Quant 7275 $24.62 24hr Vitamin B12 7610 $49.00 24hr CMV AB IGM 3110 $32.50 24hr CMV AB IGM 12486 $32.50 4 days Western Blot HIV-1 3215 $42.39 TBD Percentage Discount Allowed off fee schedule for tests not listed 65% Stat Testing Charge per specimen $16.95 Stat Courier Charge $7.74 Contract : 5753 Vendor : Quest Diagnostics Quest Fee Schedule DESCRIPTION CODE PRICE DESCRIPTION CODE PRICE ELECTROLYTES PANEL 42 $3.52 HIV1 RNA QNT RLTM PCR CSF 16186 $101.85 PROFILE 68 (SPRUE PANEL) 68 $101.85 INTERFERON BETA 1A 16201 $162.40 PROFILE 88 88 $12.78 INTERFERON BETA 1B AB 16202 $162.40 PROFILE 101 ANEMIA 101 $24.96 BUPRENORPHINE W/O CONF,UR 16207 $60.00 PROFILE 103 ELECTROLYTES 103 $4.73 ANTIMICROBIAL,RIFABUTIN 16208 $64.05 AMA HEPATIC FUNCTION PNL 104 $4.05 MAGNESIUM, 24 HOUR URINE 16213 $24.17 OBSTETRIC PANEL 125 $50.16 OPIATES CONF, UR 16215 $100.00 HEPATITIS B SURVEILLANCE 133 $53.24 MDMA/MDA, QUANT, UR 16216 $100.00 NEEDLESTICK/EXPO PROF 145 145 $44.17 HEPATOCELLULAR CARCINOMA 16222 $143.50 ALLERGEN PROFILE 184 184 $189.00 C-KIT MUTATIONS W/REFLEX 16237 $350.00 RAST FOODS COMPREHENSIVE 187 $119.00 ARBOVIRUS AB PNL, CSF 16240 $241.15 RAST HOUSEHOLD INHALANTS 188 $56.00 INFLUENZA A H1/H3 RT PCR 16251 $104.30 REGIONAL PLANTS PROFILE 189 $98.00 RESPIRATORY PNL W/H1N1 16255 $417.20 PROFILE 193 RAST 193 $182.00 BASE PROF W/CONF, UR 16259 $159.39 MYELOMA PROFILE 222 222 $89.57 BASE PROF W/O CONF, UR 16260 $159.39 AUTOIMMUNE PROFILE 224 224 $154.00 PROCALCITONIN 16265 $85.75 PROFILE 271 PRENATAL 271 $61.18 FUNGITELL(1-3)-B-D-GLUCAN 16283 $96.25 ALLERGEN PROFILE 279 279 $189.00 SRA ASSAY LMWH 16284 $91.00 PROFILE 283 IMMUNE COMPET 283 $198.35 SRA ASSAY FONDAPARINUX 16285 $91.00 C3, C4, COMPLEMENT CH50 284 $65.49 PLATELET AB SCR INDIRECT 16288 $80.50 ALLERGEN GRASSES PROFILE 300 $35.00 QUANT HIV-1 RT PCR (NIH) 16290 $103.25 ALLERGEN WEEDS PROFILE 301 $28.00 GTT GESTATIONAL 4 SPEC 16292 $14.98 ALLERGEN INDOOR INHALANTS 302 $42.00 IGF-1 ELECTROCHEM 16293 $54.25 ALLERGEN TREES PROFILE 303 $35.00 OPIATES EXPANDED,QUANT,UR 16298 $100.00 ALLERGEN MOLDS PROFILE 304 $35.00 FRAGILE X DNA ANLYS FETUS 16300 $133.00 ALLERGEN PEDIATRIC FOOD 305 $35.00 CAMPYLOBACTER SPECIES AG 16302 $33.95 ALLERGEN MEATS PROFILE 306 $28.00 BUPRENORPHINE SCR W/CONF 16310 $21.00 ALLERGEN GRAINS PROFILE 307 $35.00 XSENSE FRAGILE X W/RFLX 16313 $105.00 ALLERGEN PROFILE 311 311 $91.00 BUPRENORPHINE QUANT URINE 16314 $35.00 T-HELPER PANEL 346 $172.83 HEMOGLOBIN A1C WITH EAG 16320 $16.45 IRON,TIBC AND FERRITIN 359 $29.44 OSTEOCALCIN, N-MID 16322 $50.75 HEPATITIS PANEL, ACUTE 365 $98.31 XSENSE(R)FRAGILE X W/RFLX 16326 $327.25 ALLERGEN PROF 392 (RAST) 392 $252.00 LINEZOLID, HPLC 16328 $64.05 GLUCOSE TOLERANCE 2HR 406 $7.60 THROMBOPOIETIN (TPO) 16336 $43.75 GLUCOSE TOLERANCE 1HR 410 $7.32 GENOMIC ALTER PRENATAL 16340 $556.50 GLUCOSE TOLERANCE 2 HOUR 412 $15.79 EML4-ALK GENE FUSION PCR 16344 $192.50 GLUCOSE TOLERANCE 3HR 418 $15.79 HISTAMINE, PLASMA 16354 $47.95 GLUCOSE FAST AND GEST 425 $8.96 S PNEUMONIAE IGG AB,MAID 16374 $108.15 ALLERGEN PROF 427 (RAST) 427 $259.00 C DIFFICILE TOXON B 16377 $42.00 GTT,GESTATIONAL,4 SPEC 428 $15.79 CATECHOLAMINES SUPINE 16381 $52.85 GLUCOSE TOLERANCE 5 HOUR 441 $26.29 CATECHOLAMINES FRAC 16382 $52.85 CSF PROFILE 480 $17.85 CMV IGG/IGM CSF 16385 $59.15 MYELOMA PROFILE 635 635 $132.34 ENCEPHALITIS AB PANEL 16405 $281.40 PROFILE 688 688 $9.49 FENTANYL SCREEN UR W/RFLX 16407 $12.25 ZINC ALUMINUM SERUM 784 $70.70 EBV PANEL, CSF 16420 $104.65 DIARRHEA PROFILE 786 786 $121.07 HIV-1 GENOTYPE TROPISM 16430 $1,690.00 PROFILE 800 7 PANEL TOX 800 $8.24 HIV-1 VIRTUAL PHENOTYPE 16431 $591.50 PROFILE 819 8 PANEL TOX 819 $8.87 PNH W/FLAER 16433 $196.88 PROFILE 821 10 PANEL TOX 821 $10.11 CORTISOL FREE RESPONSE X3 16434 $131.25 PROFILE 822 9 PANEL TOX 822 $9.46 CHRONIC URTICARIA PANEL 16440 $128.10 PROFILE 866 7 PANEL TOX 866 $8.24 JC POLYOMA VIRUS DNA, CSF 16441 $104.30 THYROGLOBULIN PANEL 900 $66.33 JC POLYOMA DNA, CSF 16442 $122.15 RENAL FUNCTION PANEL 916 $4.57 JC POLYOMA VIRUS DNA, UR 16446 $122.15 COMP METAB WITH EGFR 944 $5.27 JC POLYOMA VIRUS DNA, UR 16447 $104.30 THYROID PANEL (T3U,T4,T7) 975 $11.52 TSH RECEPTOR ANTIBODY 16453 $80.50 BASIC METABOLIC 982 $4.22 PROF 1 W/CONF, UR 16454 $259.00 PAP 1 SLIDE (SCRN) 1000 $12.00 PROF 2 W/CONF, UR 16455 $159.39 HUMORAL IMMUNITY STATUS 1048 $316.40 PROF 3 W/CONF, UR 16456 $192.59 PAP INTERP BY DR 1081 $0.84 BASE PROF W/CONF, UR 16457 $159.39 ERA/PRA IMMUNOPEROXIDASE 1088 $89.18 LUNG CANCER MUTATION PNL 16461 $459.90 ERA/PRA IMMUNO NON-BREAST 1089 $96.01 STEPWISE PART 1 16463 $68.25 Contract : 5753 Vendor : Quest Diagnostics Quest Fee Schedule DESCRIPTION CODE PRICE DESCRIPTION CODE PRICE PAP,THIN LYR,RESCRN(DIAG) 1090 $22.66 STEPWISE PART 2 16465 $169.75 PAP,THIN LYR,RESCRN(SCRN) 1091 $69.50 GENOMIC ALTERATIONS 16478 $840.00 FACTOR VII AG. 1112 $180.00 PROF 4 W/CONF, UR 16483 $242.40 AMINOLEVULINIC ACID,RND 1147 $25.20 PROF 4 W/CONF, UR 16484 $242.40 POLIOVIRUS POST VACCINE 1156 $28.18 HISTOPLASMA AB PANEL, CSF 16485 $58.45 11-DEOXYCORTISOL 1205 $57.75 PROF 4 W/O CONF, UR 16486 $242.40 DRAW AND PROCESS REFERRED 1206 $28.50 HYPERSENSITIVITY PNEUMO 16490 $161.70 DRAW AND SHIP SPECIMEN 1216 $65.50 HE4,OVARIAN CANCER MONITR 16500 $89.60 ACETYLCHOLINE RECEPT.BIND 1229 $57.75 INFLM BWL DIS DIFF PANEL 16503 $175.00 FLUVOXAMINE (LUVOX) 1231 $101.00 METHYLMALONIC ACID URINE 16508 $49.70 ACTH, PLASMA 1232 $38.50 KRAS MUTATION ANALYSIS 16510 $203.00 CORTISOL, PRE ACTH 1233 $21.42 PHOSPHOLIPIDS, SERUM 16513 $27.65 CORTISOL, POST ACTH 1236 $21.42 UGT1A1 GENOTYPING 16521 $113.75 ACTH STIMULATION,PRE/POST 1237 $42.84 FISH TOP2A GENE AMP 16523 $157.50 ALUMINUM 1241 $45.85 BIOTINIDASE DEFICIENCY 16526 $262.15 ANDROSTENEDIONE,LC/MS/MS 1253 $58.45 LEPTOSPIRA AB W/RFLX 16529 $33.60 STINGING INSECT,IGE W/O T 1255 $35.00 RETICULIN IGG SCRN W/RFLX 16530 $22.75 ANTI-DNASE 1256 $22.75 1911A>G MUT ANALYSIS 16533 $104.65 GLOMERULAR BASEMENT MEMB.
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