AMERICAN ASSOCIATION OF BIOANALYSTSPROFICIENCY TESTING SERVICE

2018 ORDER FORM 800.234.5315281.436.5357

5615 Kirby Dr, Ste 870Houston, TX 77005

www.aab-pts.org E-mail: customerservice@aab-pts.org Fax 956.542.4041

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[ ] Internal use only; a copy of my results is to be sent to my laboratory only. Note: state regulations may override this request.

[ ] CLIA regulations; a copy of my results is to be sent to CMS (formerly HCFA) and my State Agency.

[ ] COLA requirements; a copy of my results is to be sent to COLA and my State Agency.

[ ] COLA requirements; a copy of my results is to be sent only to COLA.

[ ] CAP requirements; a copy of my results is to be sent to CAP. LAP No.(A copy of your certificate of accreditation from CAP is required for LAP number verification purposes.)

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Cat # Program Description X Price Total Cat # Program Description X Price TotalProvider Performed Microscopy 2009713 C-Reactive Protein, high sensitivity $45

1009693 Clinical Microscopy $15 2009763 D-Dimer $611011363 Provider Performed Microscopy $36 1009123 Drug Monitoring, Therapeutic $84

Point of Care Waived Tests 1009143 Drug Screen, Urine $912009203 Activated Clotting Time, 2-vial $89 1002033 Fecal Lactoferrin $581001155 Chemistry, i-STAT, Waived $72 1009073 Fertility Endocrinology $771011263 Chemistry, Waived $43 1009083 Fructosamine $50

A1011303 Pregnancy, Urine, Waived Add On $15 2002167 Glucose & Hemoglobin, Hemocue, 2-vial $551009143 Drug Screen, Urine $91 1009163 Glucose, WB, Basic, Single-Site $351002073 Eosinophils, Urine $25 1009183 Glucose, WB, Comprehensive, Single-Site $671002033 Fecal Lactoferrin $58 1009093 Glycohemoglobin, 2-vial $662002167 Glucose & Hemoglobin, 2-vial $55 1001973 Glycohemoglobin, 5-vial $1201009163 Glucose, WB, Basic, Single-Site $35 1001103 Hemoglobin A1C, Afinion $691009093 Glycohemoglobin, 2-vial $66 1009893 Immunochemistry $662009403 Helicobacter Pylori $56 1009813 Iron Binding (TIBC/UIBC) $511011273 Hemoglobin & Hematocrit, Waived $49 1009923 Lead, Blood, Waived $821011283 HIV Markers, Rapid, Waived $61 1009613 Lipids $521009923 Lead, Blood, Waived $82 1009643 Microalbumin/Creatinine, Urine $332001693 Mononucleosis, Infectious, 2-vial Waived Methods $33 1009783 Occult Blood, Fecal $451009783 Occult Blood, Fecal $45 1002164 Occult Blood, Gastric $611002164 Occult Blood, Gastric $61 1001113 Oximetry, Blood $1231011303 Pregnancy, Urine, Waived $29 1002503 p2PSA $712009953 Prothrombin Time, Coaguchek XS/XS Plus, Basic $65 1009153 Pregnancy, Serum or Urine $591011323 Strep Group A Antigen Screen, Waived $38 1011303 Pregnancy, Urine, Waived $291002163 Urease, Rapid (Clo-Test) $55 1002293 SHBG & Testosterone $1531009133 Urinalysis $28 1009883 Tumor Markers $1022002153 Viral Antigen Screen, Waived $63 1009133 Urinalysis $28

Chemistry Hematology1002160 Adulterated Urine $67 2009903 Blood Cell Identification $181009013 Alcohol $119 1002073 Eosinophils, Urine $261009743 Ammonia, Blood $54 2009603 ESR $541009633 Bilirubin, Direct/Neonatal, 2-vial $41 2009863 ESR Rapid $541002161 Bilirubin, Direct/Neonatal, 5-vial $77 2009283 Hematology, Centrifugal $1091009023 Blood Gases (2 sets) $154 1011273 Hemoglobin and Hematocrit, Waived $491011343 Cardiac Markers, 2-vial $75 1041953 Hemoglobin and Hematocrit, 5-vial $981009103 Cardiac Markers, 5-vial $115 2009303 Hematology, w/Diff A $1012009713F C-Reactive Protein, high sensitivity (form only) $18 2009313 Hematology, w/Diff B $119

2009763F D-Dimer(form only) $8 2009323 Hematology, w/Diff C $1191009033 Chemistry, Basic $94 2009333 Hematology, w/Diff D $1011009043 Chemistry, Comprehensive $103 2009343 Hematology, w/Diff E $1191009053 Chemistry, Basic & Comprehensive $150 2009793 Hematology, w/Diff G $119A1009613 Lipids Add On to Chemistry B/C $15 2009683 Reticulocyte Count, Automated $90

A1009813 Iron Binding Add On to Chemistry B/C $15 2002553 Reticulocyte Count, Manual $90A1009123 Drug Monitoring, Therapeutic Add on to Chemistry B/C $31 2002543 Reticulocyte Count, Sysmex $901009933 Chemistry, i-STAT, Non-Waived $119 1011333 Sickle Cell Screen $651001155 Chemistry, i-STAT, Waived $72 Coagulation1009113 Chemistry, Special $73 2009203 Activated Clotting Time, 2-vial $891009753 Chemistry, Urine/Fluids $84 2009213 Coagulation, Plasma $63A1009643 Microalbumin/Creatinine, Urine add on to U-Chem. $18 2009953 Prothrombin Time, Coaguchek XS/XS Plus, Basic $651011263 Chemistry, Waived $43 2009963 Prothrombin Time, Coaguchek XS/XS Plus, Comp. $96A1011303 Pregnancy, Urine, Waived add on to Wvd-Chem $15 2009223 Prothrombin Time, Whole Blood $102

COLUMN 1 Subtotal COLUMN 2 Subtotal

Institution Name: ___________________________________________________________________________________CLIA #: _______________________________________________________

2018 Programs Order Form - Prorated 1 Event Enrollment Deadlines - 3Q CH 9/4/18; 3Q NCH 10/22/18; 2S AEF 11/5/18

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Institution Name: ___________________________________________________________________________________International Labs ***Call 800-234-5315 option 1 or email customerservice@aab-pts.org forCLIA #: ________________________________________________________ the FedEx international shipping surcharge specific to your country.

Also includes Alaska, Hawaii, Puerto Rico, Guam & US Virgin Islands.Cat # Program Description X Price Total Cat # Program Description X Price Total

Immunohematology Mycology1001157 D (Rh) Typing $56 2001623 KOH Preparation $672009873 Direct Antiglobulin Test (DAT) $74 Andrology, Embryology & Fetal Tests2001663 Fetal RBC (2 testing events per year) $157 3009234 Antisperm Antibodies $1402009353 Immunohematology, Basic $90 3009974 Embryo Grading $1422009363 Immunohematology, Comprehensive $136 3009654 Fetal Fibronectin (fFN) $1902002123 Immunohematology, Comprehensive Plus $154 3001164 Fetal Membrane Rupture $176

Immunology/Serology 1001244 IVF Embryology Culture Media $2202009373 Anti-nuclear Antibody $62 3002514 Preimplantation Genetic Screening $4262009383 Anti-streptolysin O $53 3009254 Sperm Count, for Quant & Qual (Post-vasectomy) $1402009393 C-Reactive Protein $35 3009264 Sperm Morphology $1402002313 Diagnostic Immunology $150 3009984 Sperm Motility $1432009403 Helicobacter Pylori $56 3009274 Sperm Viability $1402009623 Hepatitis Markers $90 Specialty Programs2009443 HIV Antibodies, 5-vial, Oral Fluid $130 2001583 Circulating Tumor Cell (CTC) $1211011283 HIV Markers, Rapid, Waived $61 1002453 eGFR (3 events per year) $1682009483 HIV Markers $84 1002463 Cholesterol Certification (2 events per year) $5612009413 Immunoproteins $79 1009173 Glucose, WB, Basic, EQAS (Multisite) $592009433 Lyme Disease $71 Instrument Comparison qty2001693 Mononucleosis, Infectious, 2-vial Waived Methods $33 40023 Blood Gases - Primary + 1 Secondary $592009423 Mononucleosis, Infectious $56 A40023 Blood Gases - each additional Secondary $212001733 Mycoplasma Antibody $69 40103 Cardiac Markers - Primary + 1 Secondary $982009453 Rheumatoid Factor $54 A40103 Cardiac Markers - each additional Secondary $712009463 Rubella $62 41343 Cardiac Markers, 2 vial - Primary + 1 Secondary $592009473 Syphilis Serology $69 A41343 Cardiac Markers, 2 vial - each additional Secondary $491011355 ToRCH (2 testing events per year) $132 40053 Chemistry, Basic/Comp - Primary + 1 Secondary $68

Microbiology A40053 Chemistry, Basic/Comp - each additional Secondary $262009495 Acid-Fast Smears (2 testing events per year) $100 40933 Chemistry, i-STAT, Non-Waived - Primary + 1 Secondary $582009503 Bacteriology $115 A40933 Chemistry, i-STAT, Non-Waived - each addn'l Secondary $201011393 Bacteriology, Complete $138 41553 Chemistry, i-STAT, Waived -Primary + 1 Secondary $402009723 C. Difficile Antigen, 5-vial $115 A41553 Chemistry, i-STAT, Waived -each additional Secondary $182002183 Campylobacter-addon any 5vial culture or bacterial antigen $35 40123 Drug Monitoring, Therapeutic - Primary + 1 Secondary $682009513 Chlamydia/GC/Strep B $153 A40123 Drug Monitoring, Therapeutic - each addn'l Secondary $262009673 Cryptosporidium/Giardia, 5-vial $84 41113 Oximetry, Blood - Primary + 1 Secondary $632009523 Genital Culture, 5-vial $94 A41113 Oximetry, Blood - each additional Secondary $302009543 Gram Stain, 5-well slide $64 40203 Activated Clotting Time, 2-vial - Primary + 1 Secondary $1892001723 MRSA $77 A40203 Activated Clotting Time, 2-vial - each addn'l Secondary $1012009553 Parasitology $104 40303 Hematolgy w/ Diff A - Primary + 1 Secondary $97

A2002173 Rotavirus, 2-vial - add on to 5-viral antigen screen $64 40313 Hematolgy w/ Diff B - Primary + 1 Secondary $1132002163 Rotavirus, 5-vial $113 40323 Hematolgy w/ Diff C - Primary + 1 Secondary $1131011323 Strep Group A Antigen Screen, Waived $38 40333 Hematolgy w/ Diff D - Primary + 1 Secondary $972009563 Strep Group A Antigen Screen $73 40343 Hematolgy w/ Diff E - Primary + 1 Secondary $1132001743 Shiga Toxin $82 40793 Hematolgy w/ Diff G - Primary + 1 Secondary $1132009573 Throat Culture $113 COLUMN 4 Subtotal2009583 Throat/Urine Culture w/Colony Count $113 COLUMN 3 Subtotal1002163 Urease, Rapid (Clo-Test) $55 COLUMN 2 Subtotal2091063 Urine Colony Count $71 COLUMN 1 Subtotal2009593 Urine Culture w/Colony Count $104 Total Program Order2009803 Vaginosis $141 Annual Registration & Shipping Fee (must accompany all orders) $332002153 Viral Antigen Screen, 2-vial Waived $91 International Labs Shipping Surcharge*** (if applicable)

2009733 Viral Antigen Screen $127 Total Payment DueCOLUMN 3 Subtotal

2018 Programs Order Form

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