| Ultrasound transvaginal CPT 76830 • Imaging | $80 | $80 | $80 |
| Venipuncture (routine blood draw) CPT 36415 • Lab | $1 | $3 | $6 |
| Urinalysis non-automated without microscopy CPT 81002 • Lab | $2 | $2 | $2 |
| Strep test rapid (Streptococcus group A direct) CPT 87880 • Lab | $8 | $9 | $10 |
| Basic metabolic panel CPT 80048 • Laboratory | $5 | $6 | $7 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $6 | $7 | $9 |
| Lipid panel CPT 80061 • Laboratory | $8 | $10 | $10 |
| Hepatic function panel CPT 80076 • Laboratory | $5 | $6 | $7 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $2 | $2 | $3 |
| Urinalysis automated without microscopy CPT 81003 • Laboratory | $1 | $2 | $2 |
| Fecal hemoglobin immunoassay CPT 82274 • Laboratory | $10 | $12 | $15 |
| Vitamin D 25-hydroxy CPT 82306 • Laboratory | $16 | $19 | $23 |
| Creatine kinase (CK) total CPT 82550 • Laboratory | $4 | $4 | $4 |
| Creatinine urine CPT 82570 • Laboratory | $3 | $3 | $3 |
| Ferritin CPT 82728 • Laboratory | $7 | $9 | $10 |
| IgA IgD IgG IgM each CPT 82784 • Laboratory | $6 | $7 | $9 |
| Glucose quantitative blood CPT 82947 • Laboratory | $3 | $3 | $4 |
| Hemoglobin A1c CPT 83036 • Laboratory | $6 | $8 | $9 |
| Iron serum CPT 83540 • Laboratory | $4 | $5 | $6 |
| Iron binding capacity CPT 83550 • Laboratory | $5 | $5 | $6 |
| Prostate specific antigen (PSA) CPT 84153 • Laboratory | $12 | $14 | $17 |
| Free thyroxine (T4) CPT 84439 • Laboratory | $6 | $7 | $8 |
| Thyroid stimulating hormone (TSH) CPT 84443 • Laboratory | $11 | $13 | $15 |
| Complete blood count with differential CPT 85025 • Laboratory | $5 | $5 | $6 |
| Complete blood count automated CPT 85027 • Laboratory | $4 | $5 | $6 |
| Prothrombin time (PT) CPT 85610 • Laboratory | $3 | $3 | $3 |
| Sedimentation rate (ESR) automated CPT 85652 • Laboratory | $2 | $2 | $2 |
| Partial thromboplastin time (PTT) CPT 85730 • Laboratory | $4 | $4 | $6 |
| Cyclic citrullinated peptide antibody CPT 86200 • Laboratory | $8 | $10 | $12 |
| Nuclear antigen antibody CPT 86235 • Laboratory | $12 | $13 | $17 |
| Heterophile antibodies screen CPT 86308 • Laboratory | $3 | $4 | $5 |
| TB skin test intradermal CPT 86580 • Laboratory | $4 | $4 | $4 |
| Blood typing ABO CPT 86900 • Laboratory | $2 | $2 | $3 |
| Blood typing Rh CPT 86901 • Laboratory | $2 | $2 | $3 |
| Urine culture bacterial colony count CPT 87086 • Laboratory | $5 | $6 | $7 |
| Chlamydia nucleic acid amplification CPT 87491 • Laboratory | $23 | $26 | $32 |
| Gonorrhea nucleic acid amplification CPT 87591 • Laboratory | $23 | $26 | $32 |
| SARS-CoV-2 COVID-19 amplified probe CPT 87635 • Laboratory | $31 | $38 | $51 |
| Influenza virus assay with direct optical CPT 87804 • Laboratory | $8 | $9 | $11 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $77 | $77 | $77 |
| Brief emotional/behavioral assessment CPT 96127 • Mental Health | $5 | $5 | $5 |
| Office visit new patient low complexity CPT 99203 • Office Visits | $65 | $65 | $65 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $100 | $100 | $100 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $126 | $126 | $126 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $30 | $30 | $30 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $43 | $43 | $43 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $30 | $30 | $30 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $30 | $30 | $30 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $46 | $46 | $46 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $67 | $67 | $67 |