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Download CPT code - Raj Dalal, MD
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Discount Lab order for Self pay (Cash or Credit only, will not be billed to insurance) Patient Name: Date of Birth: CPT code Test Description Cost 10165 10256 14852 5493 6399 17306 899 866 809 10157 496 6517 15980 4420 457 763 927 36170 470 19867 8472 498 Basic Metabolic Panel Liver Panel Lipid Profile with reflex to LDL Complete Urinalysis CBC with differential Vitamin D (25 Hydroxy) TSH Free T4 Sed rate by Westergreen Screening PSA A1C HGB Micro albumin w/creatinine Celiac panel CRP Ferritin Magnesium B12 Testosterone level, total and free FSH RA panel (RF, CCP, ANA choice) HEPATITIS C ANTIBODY HEPAITIS B SURFACE ANTIGEN 35.00 35.00 104.00 24.00 35.00 220.00 35.00 65.00 45.00 65.00 65.00 80.00 400.00 40.00 95.00 24.00 70.00 200.00 80.00 400.00 72.00 72.00 747 4446 905 Serum Protein Electrophoresis Blood Cultures (aerobic and anaerobic)-2 Uric Acid 120.00 240.00 84.00 Total Cost Please fast overnight for about 12 hours before getting the test done Patient Signature (Permission to do the lab test with Quest lab):_______________ Date of Signature and lab test: _______________ Physician’s Signature:____________ Raj Dalal, M.D. Internal Medicine, 192, Abner Jackson Parkway, Lake Jackson, TX (979) 285-0007
