SurveyMonkey Website Captured 2/4/2021

 https://www.surveymonkey.com/r/MolecularDiagnosticPathology

* 1. Procedure Code

2. Clinical Vignette

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3. How was this service billed previously?

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4. Please classify the test billed under the applicable code as one of the following (check one):

Lab developed test

FDA-cleared/approved in vitro-diagnostic test

Modified FDA-cleared/approved

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5. List the resources required to perform the test and the cost:

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6. Total charges for the test and routine discounts to the charges:

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7. If applicable, charges, payment amounts, and resources required for other test(s) that may be comparable or otherwise relevant:

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8. Please provide your direct/indirect costs associated with this test (please be specific):

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9. Additional comments or information:

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10. Please click here if you would like to attach additional supporting documentation:

 

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* 11. Address

Name

Company

Address

City/Town

State/Province                   -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming                  

ZIP/Postal Code

Email Address

Phone Number