| Hemoglobin A1c CPT 83036 • Laboratory | $14 | $14 | $14 |
| Iron serum CPT 83540 • Laboratory | $3 | $3 | $3 |
| Iron binding capacity CPT 83550 • Laboratory | $7 | $7 | $7 |
| Prostate specific antigen (PSA) CPT 84153 • Laboratory | $10 | $10 | $10 |
| Free thyroxine (T4) CPT 84439 • Laboratory | $7 | $7 | $7 |
| Thyroid stimulating hormone (TSH) CPT 84443 • Laboratory | $9 | $9 | $9 |
| Complete blood count with differential CPT 85025 • Laboratory | $11 | $11 | $11 |
| Complete blood count automated CPT 85027 • Laboratory | $9 | $9 | $9 |
| Prothrombin time (PT) CPT 85610 • Laboratory | $5 | $5 | $5 |
| Sedimentation rate (ESR) automated CPT 85652 • Laboratory | $4 | $4 | $4 |
| Partial thromboplastin time (PTT) CPT 85730 • Laboratory | $4 | $4 | $4 |
| Cyclic citrullinated peptide antibody CPT 86200 • Laboratory | $12 | $12 | $12 |
| Nuclear antigen antibody CPT 86235 • Laboratory | $17 | $17 | $17 |
| Heterophile antibodies screen CPT 86308 • Laboratory | $7 | $7 | $7 |
| TB skin test intradermal CPT 86580 • Laboratory | $10 | $10 | $10 |
| Blood typing ABO CPT 86900 • Laboratory | $2 | $2 | $2 |
| Blood typing Rh CPT 86901 • Laboratory | $2 | $2 | $2 |
| Urine culture bacterial colony count CPT 87086 • Laboratory | $11 | $11 | $11 |
| Chlamydia nucleic acid amplification CPT 87491 • Laboratory | $24 | $24 | $24 |
| Gonorrhea nucleic acid amplification CPT 87591 • Laboratory | $24 | $24 | $24 |
| Influenza virus assay with direct optical CPT 87804 • Laboratory | $16 | $16 | $16 |
| Strep A assay with optic observation CPT 87880 • Laboratory | $16 | $16 | $16 |
| Office visit new patient straightforward CPT 99202 • Office Visits | $89 | $89 | $89 |
| Office visit new patient low complexity CPT 99203 • Office Visits | $130 | $130 | $130 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $132 | $166 | $199 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $180 | $215 | $250 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $53 | $54 | $55 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $86 | $86 | $86 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $97 | $113 | $129 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $139 | $139 | $139 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $124 | $135 | $147 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $170 | $170 | $170 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $250 | $250 | $250 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $52 | $52 | $52 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $92 | $92 | $92 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $132 | $132 | $132 |
| Cytopathology concentration technique CPT 88108 • Pathology | $30 | $30 | $30 |
| Cytopathology cell enhancement technique CPT 88112 • Pathology | $75 | $75 | $75 |
| Cytopathology cervical/vaginal interpretation physician CPT 88141 • Pathology | $16 | $16 | $16 |
| Cytopathology cervical/vaginal manual screen CPT 88164 • Pathology | $5 | $5 | $5 |
| Cytopathology cervical/vaginal automated thin layer CPT 88175 • Pathology | $24 | $24 | $24 |
| Molecular cytogenetics DNA probe each CPT 88271 • Pathology | $14 | $14 | $14 |
| Cytogenetics molecular interpretation CPT 88291 • Pathology | $4 | $4 | $4 |
| Surgical pathology gross and micro exam level II CPT 88302 • Pathology | $24 | $24 | $24 |
| Surgical pathology gross and micro exam level III CPT 88304 • Pathology | $7 | $7 | $7 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $23 | $23 | $23 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $93 | $93 | $93 |
| Surgical pathology gross and micro exam level VI CPT 88309 • Pathology | $132 | $132 | $132 |
| Special stain group I for microorganisms CPT 88312 • Pathology | $31 | $31 | $31 |
| Special stain group II CPT 88313 • Pathology | $31 | $31 | $31 |