| Blood typing ABO CPT 86900 • Laboratory | $4 | $4 | $4 |
| Blood typing Rh CPT 86901 • Laboratory | $4 | $4 | $4 |
| Urine culture bacterial colony count CPT 87086 • Laboratory | $10 | $10 | $10 |
| Chlamydia nucleic acid amplification CPT 87491 • Laboratory | $39 | $39 | $39 |
| Gonorrhea nucleic acid amplification CPT 87591 • Laboratory | $39 | $39 | $39 |
| SARS-CoV-2 COVID-19 amplified probe CPT 87635 • Laboratory | $51 | $51 | $51 |
| Influenza virus assay with direct optical CPT 87804 • Laboratory | $21 | $21 | $21 |
| Strep A assay with optic observation CPT 87880 • Laboratory | $13 | $13 | $13 |
| Fetal non-stress test CPT 59025 • Maternity | $11 | $31 | $50 |
| Obstetric ultrasound first trimester CPT 76801 • Maternity | $164 | $164 | $164 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $164 | $164 | $164 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $44 | $77 | $110 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $50 | $85 | $120 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $183 | $183 | $183 |
| Electroencephalogram (EEG) awake and asleep with activation CPT 95819 • Neurology | $224 | $224 | $224 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $163 | $163 | $163 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $65 | $65 | $65 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $115 | $115 | $115 |
| Cataract surgery complex with intraocular lens CPT 66982 • Ophthalmology | $1,123 | $1,123 | $1,123 |
| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $44 | $450 | $855 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $84 | $84 | $84 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $44 | $422 | $801 |
| Total hip replacement CPT 27130 • Orthopedics | $1,674 | $1,674 | $1,674 |
| Total knee replacement CPT 27447 • Orthopedics | $1,803 | $1,803 | $1,803 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $44 | $213 | $381 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $783 | $783 | $783 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $44 | $430 | $816 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $1,323 | $1,323 | $1,323 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $781 | $781 | $781 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $724 | $724 | $724 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $1,041 | $1,041 | $1,041 |
| Carpal tunnel release CPT 64721 • Orthopedics | $453 | $453 | $453 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $122 | $122 | $122 |
| Epidural injection lumbar or sacral transforaminal CPT 64483 • Pain Management | $437 | $437 | $437 |
| Cytopathology cell enhancement technique CPT 88112 • Pathology | $149 | $149 | $149 |
| Surgical pathology gross and micro exam level II CPT 88302 • Pathology | $38 | $38 | $38 |
| Surgical pathology gross and micro exam level III CPT 88304 • Pathology | $51 | $51 | $51 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $117 | $117 | $117 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $201 | $201 | $201 |
| Special stain group I for microorganisms CPT 88312 • Pathology | $88 | $88 | $88 |
| Special stain group II CPT 88313 • Pathology | $62 | $62 | $62 |
| Immunohistochemistry first antibody CPT 88342 • Pathology | $104 | $104 | $104 |
| Morphometric analysis tumor quantitative CPT 88360 • Pathology | $45 | $74 | $104 |
| Hot or cold packs application CPT 97010 • Physical Therapy | $6 | $6 | $6 |
| Vasopneumatic device therapy CPT 97016 • Physical Therapy | $18 | $18 | $18 |
| Electrical stimulation attended each 15 minutes CPT 97032 • Physical Therapy | $20 | $20 | $20 |
| Ultrasound therapy each 15 minutes CPT 97035 • Physical Therapy | $15 | $15 | $15 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $36 | $36 | $36 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $36 | $36 | $36 |
| Gait training each 15 minutes CPT 97116 • Physical Therapy | $31 | $31 | $31 |