Hepatitis B Core AB Total 86704

Hepatitis Delta AB 87380Hepatitis B Core AB (IgM) 86705

Hepatitis C RNA Quant. 87522

Iron 83540Iron/TIBC 83540/ 83550

Abnominal Pain 789.00

Abnormal Liver 794.8Abnormal PSA 790.93

Abnormal Renal 794.4

Abnormal Sed Rate 790.1

Abnormal Thyroid 794.5

ADD 314.00

ADHD 314.01

Allergic Rhinitis 477.9

Amenorrhea 626.0

Anemia 280.9

Anxiety Disorder, Generalized 300.02

Arrhythmia, NOS 427.9

Arteriosclerosis Cerebral/CNS 437.0

Arthritis, NOS 716.90

Arthritis, Osteo 715.90

Arthritis, Rheumatoid 714.0

ASHD 414.00

Asthma 493.90

Atrial Fibrillation 427.31

Blurred Vision 368.8

Bradycardia 427.89

Diabetes, Gestational 648.80

Diabetes Mellitus, Juvenile 250.01

Diabetes Mellitus, Type II, Comp. 250.90

Diabetes Mellitus, Type II, Uncomp. 250.00

Diarrhea, NOS 787.91

Diverticulitis 562.11

Herpes Zoster 053.9

Hirsutism 704.1

Hypercalcemia 275.42

Hypercholesterolemia 272.0

Hyperkalemia 276.7

Prostate Hyperplasia 600

Prostatitis, Acute 601.0

Proteinuria 791.0

PVD 443.9

Rash 782.1

Bronchitis, Acute 466.0

Dizziness, Light Headed 780.4

Cancer, Prostate 185.0

Cervicitis 616.0

Chest Pain 786.50

Cirrhosis 571.85

Colitis, Unspecified 558.9

Congestive Heart Failure 428.0

Contact Dermatitis 692.9

COPD 496.

Coronary Artery Disease 414.9

Coumadin Therapy V58.61

CVA/TIA 435.9

Dehydration 276.5

Depression 311.

Depression, Manic 296.80

Diabetes, CRF, Uncontrolled 250.42

Edema 782.3Hyperlipidemia 272.2

Fatigue, Lethargy 780.79Fever 780.6

Fibromyalgia /Myalgia 729.1

Gastritis, Acute 535.00

GE Reflux 530.81

Glycosuria 791.5

Goiter 240.9

Gout 274.9

Grave’s Disease 242.00

Headache 784.0

Hemochromatosis 275.0

Hematuria 599.7

Hemorrhoids 455.6

Hepatitis B 070.3

Hepatitis C 070.51

Menorrhagia 626.2

Lymphadenopathy 785.6

Medication, long term use V58.69

Menopausal Syndrome 627.2

Hypertension 401.1

Hyperthyroidism 242.90Hypertriglyceridemia 272.1

Hypocalcemia 275.41

Hypoglycemia 251.2

Hypogonadism-male 257.2

Hypothyroidism 244.9

Impotence 607.84

Influenza 487.1

Irregular Menses 626.4

Irritable Bowel 564.1

Joint Pain 719.40

Kidney Stone 592.0

Labyrinthitis 386.30

Loss Of Appetite 783.0

Low Back Syndrome 724.2

Metrorrhagia 626.6

Rectal Bleeding 569.3

Mononucleosis 075.Morbid Obesity 278.01

Multiple Sclerosis 340.

Nausea 787.0

Normal State V65.5

Normal Pelvic Exam V72.3

Onyohomychosis 110.1

Osteoporosis 733.00

Palpitations 785.1

Peripheral Artery Disease 747.60

Pharyngitis, Strep 034.0

Pharyngitis, Viral 462.

Pituitary Hypersecretion 253.1

Pneumonia 486

Preoperative Exam V72.83

Screening, Cancer V76.9

Screening Cholesterol V77.9Seizure 780.39

Sinusitis, Acute 461.9

Suspect Malignant Neoplasm V71.1

Thyroid Nodule 241.0

Thyroiditis 245.9

Tick Bite 066.1

URI 465.9

UTI 599.0

Vaginitis/ Vulvitis 616.10

Viral Syndrome 079.99

Weight Gain, Abnormal 783.1

Weight Loss 783.21

DIAGNOSIS

Abnormal Glucose 790.2

Abnormal Enzymes 790.5

Cancer, Thyroid 193.

Constipation 564.00

PHYSICIANSSIGNATURE___________________________________________________________________

FAX / MAIL RESULTS TO: TOTAL FOR SERVICE $AMOUNT PAID $

TO

PAID BY ¨ CHECK ¨ CREDIT CARD ¨ CASH

PROCEDURE CODE FEECBC 85025Comprehensive Metabolic Panel 80053Basic Metabolic Panel 80048Electrolytes 80051Hepatic Function Panel 80076Renal Function Panel 80069Lipid Profile 80061Direct LDL 83721

Acute Hepatitis Panel 80074

Glucose 82947Bun 84520Creatinine 82565Sodium 84295

FSH 83001

PROCEDURE CODE FEE

DHEA-S 82627

C-Reactive Protein 86140C-Peptide 84681CEA 82378

C-Reactive Protein, Cardiac 86141Cortisol, Serum 82533CPK, Total 82550CMV 86644

Eosinophil Count 85048Ferritin 82728Folic Acid 82746Free T4 Equilibrium Dialysis 84439

PROCEDURE CODE FEELyme Antibodies (IgG, IgM, IgA) 86318Lyme Antibody (IgM Only) 86617Lyme-Western Blot x2 86617Magnesium 83735Mono Screen 86308

PROCEDURE CODE FEE

Progesterone 84144Prolactin 84146

DRUG LEVELS

URINE TESTS AND MICROBIOLOGY

Alcohol Serum 82055Carbamazepine (TEGRETOL) 80156Digoxin 80162Doxepin 80166Lithium 80178Phenobarbital 80184Phenytoin (DILANTIN) 80185Primidone(MYSOLINE)(incl.phenobarb) 86790Procainamide (NAPA) 80192Theophylline 80198Valproic Acid (DEPAKOTE) 80164Quinidine 80194

Potassium 84132Chloride 82435Carbon Dioxide 82374ALT / Sgpt 84460AST / Sgot 84450GGT 82977LDH 83615Cholesterol 82465Triglycerides 84478Uric Acid 84550Calcium 82310Phosphorus 84100Albumin 82040Total Protein 84155Total Bili 82247Direct Bili 82248Alk Phos 84075

Alpha Fetoprotein 82105Amylase 82150Androstenedione 82157ANA 86038CD4 Count (Includes CBC)CD4 / CD8 (Includes CBC)

Hemoglobin AIC 83036HCG Qualitative 84703HCG Quantitative 84702HDL 83718Helicobacter Pylori 86677Hemoglobin Electrophoresis 83020Hepatitis A Antibody 86708

Human Growth Hormone 83003Hydroxyprogesterone (17) 83498Immunoglobulin E 82785Insulin 83525

Lead 83655LH 83002Lipase 83690

Protime 85610PTT 85730Protein EleotrophoresisPSA G0103 / 84153PTH-Intact with Calcium 83970 / 82310Reticulocyte Count 85044Rheumatoid Factor 86430RPR 86592Rubella Screen 86762Rubeola Titer 86765Sed Rate 85651Sickle Cell Test 85660Somatomedin 84305Streptozyme 86590Testosterone 84403Varicella Titer 86787Vitamin B12 82607Vitamin D, 25-Hydroxy 82306Vitamin D, 1-25 Di Hydroxy 82652

THYROID TESTSTSH 84443Total T4 84436T3 Uptake 84479Total T3 84480

Free T3 84481Free T4 84439Free T4 Equilibrium Dialysis 84439Thyroid Autoantibodies 86800 / 86376Thyroglobulin 84432Thyroid Stimulating Immunoglobulin 84445

Pregnancy, Urine 81025Protein, Urine 24 HOURS 84155Routine Culture 87070Strep A Screen, Rapid 87880Strep Culture, Throat 87081Throat Culture, (All Pathogens) 87070Urinalysis, Automated 81003Urine Culture 87086VMA 24 Hours 84585Venipuncture G0001 / 36415Lab Processing Fee 99001

Blood Culture 87040Catecholamines 24 HOURS 82382Chlamydia DNA Probe 87797Cortisol, Urine 82533Creatinine, Urine 24 HOURS 82570Creatinine Clearance 82575Drug Screen, Urine 80100Fecal Occult Blood G0107 / 82270GC DNA Probe 87797Gram Stain 87205Metanephrines 24 HOURS 83835Microal / Creat Ratio 82043 / 82570O & P 87177Pap Smear 88142

Albumin Urine 24 HOUR 82042

MEDICAL HEALTH LAB2000 Stelton Rd, Piscataway, NJ 08854

Tel: (732) 562-0000 ext. 7 l Fax: (732) 463-2222

TECHNICAL SUPERVISOR - VIRGINIA BABLE, MT, ASCPMEDICAL DIRECTOR - ALIETA ELL, MD

MEDICARE # 541222EIN - 22-31725290CLIA # 31D0891922

Referring Physician:Ara Apel, MD

Internal Medicine, Endocrinology Lic# MA 47582Alieta Eldridge, MD

Internal Medicine, Lic# MA 39925John Smith, MD

Family Medicine, Lic# MA 40377Cecil Mulives, MD

Internal Medicine, Infectious Diseases, Lic# MO 56362

PHYSICIAN'S STATEMENTAND INSURANCE REPORT

Patient: Fasting: Yes No ____ Hour Post-Prandial Time Drawn: Date of Service:

Hepatitis Be Antigen 87350Hepatitis B S Antibody 86706Hepatitis B S Antigen 86287Hepatitis C Antibody (EIA) 86302

Hepatitis C GenotypeHIV- 1 & 2 Screen 86703HIV- V

iral RNA