CLIA ID: 45D0503753 CAP ID: 2148801 Tax ID # 32-0113643 NPI # 190-282-4881 Effective (September 01, 2014) DSHS LABORATORY SERVICES SECTION FEE SCHEDULE - South Texas Laboratory HUMAN TESTING: NOTE: Specimens that must be sent to a reference laboratory for testing will be billed at the reference laboratory price plus an additional $3.00 handling fee. South Texas Laboratory Bacteriology Procedure Name Aerobic isolation, definitive identification, Streptococcus screen Fecal occult blood Fecal white blood cell (WBC) smear Gram Stain KOH exam for skin, hair nails Urine Culture Wet mount, vaginal South Texas Laboratory Clinical Chemistry Procedure Name Alanine Amino Transferase (ALT) Albumin, serum, urine or other source Alkaline phosphatase Amylase, serum Aspartate aminotransferase (AST) Bilirubin, Direct Bilirubin, total Bilirubin, Total & Direct Profile Blood urea nitrogen (BUN) Calcium Carbon dioxide (CO2) Chloride, serum Cholesterol: total High-density lipoprotein (HDL) Low-density lipoprotein (LDL) Creatine kinase (CK) assay Creatinine assay Electrolyte panel Gamma-glutamyl transferase (GGT) Glucose Glucose tolerance test, 2 hour Glucose postprandial, 0 and 2 hours Hepatic function panel Procedure No. CPT Cost 87880 9.94 HZZ0062 HZZ0060 HZZ0111 HZZ0061 HZZ0113 HZZ0070 82270 89055 87205 87220 87086 87210 3.94 11.67 8.06 7.85 11.59 9.14 Procedure No. HZZ0004 HZZ0001 HZZ0003 HZZ0005 HZZ0006 HZZ0007 HZZ0008 CPT Cost 84460 82040 84075 82150 84450 82248 82247 82247/82248 1.34 1.27 1.37 7.37 1.32 1.69 1.30 2.44 HZZ0009 HZZ0010 HZZ0013 HZZ0011 84520 82310 82374 82435 1.48 1.64 1.35 1.35 HZZ0012 HZZ0018 HZZ0055 HZZ0016 HZZ0002 HZZ0047 HZZ0014 HZZ0015 HZZ0044 HZZ0017 HZZ0051 82465 83718 83721 82550 82565 80051 82977 82947 82951 82950 80076 1.36 1.37 2.20 2.79 1.30 2.83 3.90 1.34 1.37 1.34 2.47 HZZ0065 PZZ0002 Hemoglobin A1C Iron binding capacity, total Iron, total Lactic acid dehydrogenase (LDH) Lipase Lipid profile panel Magnesium Metabolic Basic panel Metabolic Comprehensive panel Phosphorus Potassium Protein, total Renal function panel Sodium Triglycerides Tuberculosis Custom Panel- HZZ0054 HZZ0056 HZZ0019 HZZ0020 HZZ0021 HZZ0050 HZZ0022 HZZ0052 HZZ0053 HZZ0023 HZZ0024 HZZ0026 HZZ0049 HZZ0025 HZZ0027 PZZ0004 Uric acid HZZ0028 83036 83550 83540 83615 83690 80061 83735 80048 80053 84100 84132 84155 80069 84295 84478 84075, 84550, 82247, 84450, 84460,82465,8 256 5,84520, 82977 84550 10.37 8.55 7.08 8.17 20.43 8.84 7.82 3.65 6.39 11.56 1.35 1.41 18.13 1.35 1.36 10.36 4.07 Emergency Preparedness Human and Non-Human Testing: Emergency Preparedness: Biothreat specimens and testi ng requests accepted from Law Enforcement Officials Only. Please Contact the Emergency Preparedness Branch of the DSHS South Texas Laboratory for more information. South Texas Laboratory Hematology Procedure Name CBC (complete blood count) with smear review South Texas Laboratory Immunology Microbiology HZZ0057 & HZZ0071 CPT Cost 85025, 85008 9.11 CBC complete, automated with differential Differential, manual Hematocrit Hemoglobin, total Peripheral Smear Review Sedimentation rate HZZ0057 HZZ0058 HZZ0038 HZZ0037 HZZ0071 HZZ0039 85025 85007 85014 85018 85008 85652 1.51 9.89 6.01 6.01 7.59 11.38 Procedure Name Procedure No. CPT Cost HZZ0041 HZZ0042 HZZ0043 84703 81025 86430 4.40 4.24 4.73 Procedure No. CPT Cost Pregnancy test: serum urine Rheumatoid factor South Texas Laboratory Procedure No. Procedure Name Mycobacteriology, Acid fast bacillus (AFB): concentration culture, any source identification of AFB isolate, DNA probe identification, referred isolates, DNA probe smear only Drug susceptibility studies: conventional susceptibility (each drug) MGIT susceptibility (each drug) MGIT susceptibility (each drug)PZA Parasitology: Ova & parasites (concentration and trichrome stain) Serology, Syphilis: Rapid plasma reagin (RPR): screen (qualitative) titer (quantitative) Confirmation particle agglutination (TP-PA) South Texas Laboratory Special chemistry Procedure Name Ferritin Follicle stimulating hormone (FSH) Leuteinizing hormone (LH) Prolactin Prostate specific antigen (PSA), total Thyroxine(T4), Free Thyroxine(T4), total Thyroid Hormone (T3) uptake Thyroid stimulating hormone (TSH) Tri-iodothyronine (T3), free South Texas Laboratory Urinalysis Procedure Name Creatinine clearance test Protein, total, 24 hour Microscopy with urinalysis (UA) Random Urine/Creatinine Profile Urinalysis, no reflex Urine microalbumin, random Urine Microscopic Analysis South Texas Laboratory Environmental NON-HUMAN TESTING: Procedure Name Water bacteriology, potable water HZZ0073 HZZ0093 HZZ0075 87015 87116 87149 HZZ0075 87149 HZZ0074 87206 5.09 87190 14.06 87188 87188 43.47 92.69 87177, 87209 67.17 HZZ0105 HZZ0106 HZZ0107 86592 86593 86780 7.99 7.99 9.30 Procedure No. HZZ0029 HZZ0031 HZZ0032 HZZ0072 HZZ0033 HZZ0030 HZZ0034 HZZ0036 HZZ0035 HZZ0112 CPT Cost 82728 83001 83002 84146 84143 84439 84436 84479 84443 84481 22.31 15.10 17.83 18.07 27.90 10.89 35.53 23.67 9.41 19.10 CPT Cost 82575 84156 81001 84156/82565 81003 82044 81015 12.00 5.82 32.25 6.44 5.24 5.69 5.54 CPT Cost Non-Human test 8.82 HZZ0117 HZZ0118 HZZ0119 PZZ0001 Procedure No. HZZ0048 HZZ0066 HZZ0067 PZZ0003 HZZ0059 HZZ0040 HZZ0068 Procedure No. HZZ0090 4.31 49.89 44.63 44.63
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