| Complete blood count with differential CPT 85025 • Laboratory | $6 | $6 | $6 |
| Complete blood count automated CPT 85027 • Laboratory | $5 | $5 | $5 |
| 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 | $5 | $5 | $5 |
| Cyclic citrullinated peptide antibody CPT 86200 • Laboratory | $10 | $10 | $10 |
| Nuclear antigen antibody CPT 86235 • Laboratory | $14 | $14 | $14 |
| Heterophile antibodies screen CPT 86308 • Laboratory | $4 | $4 | $4 |
| TB skin test intradermal CPT 86580 • Laboratory | $8 | $8 | $8 |
| 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 | $6 | $6 | $6 |
| Chlamydia nucleic acid amplification CPT 87491 • Laboratory | $28 | $28 | $28 |
| Gonorrhea nucleic acid amplification CPT 87591 • Laboratory | $28 | $28 | $28 |
| SARS-CoV-2 COVID-19 amplified probe CPT 87635 • Laboratory | $51 | $51 | $51 |
| Influenza virus assay with direct optical CPT 87804 • Laboratory | $13 | $13 | $13 |
| Strep A assay with optic observation CPT 87880 • Laboratory | $13 | $13 | $13 |
| Obstetric ultrasound first trimester CPT 76801 • Maternity | $165 | $165 | $165 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $171 | $171 | $171 |
| Obstetric ultrasound detailed fetal anatomy CPT 76811 • Maternity | $122 | $122 | $122 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $71 | $71 | $71 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $47 | $47 | $47 |
| Cytopathology concentration technique CPT 88108 • Pathology | $32 | $32 | $32 |
| Cytopathology cell enhancement technique CPT 88112 • Pathology | $51 | $51 | $51 |
| Cytopathology cervical/vaginal interpretation physician CPT 88141 • Pathology | $17 | $17 | $17 |
| Cytopathology cervical/vaginal manual screen CPT 88164 • Pathology | $13 | $13 | $13 |
| Cytopathology cervical/vaginal automated thin layer CPT 88175 • Pathology | $21 | $21 | $21 |
| Molecular cytogenetics DNA probe each CPT 88271 • Pathology | $17 | $17 | $17 |
| Cytogenetics molecular interpretation CPT 88291 • Pathology | $26 | $26 | $26 |
| 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 | $32 | $32 | $32 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $26 | $26 | $26 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $155 | $155 | $155 |
| Surgical pathology gross and micro exam level VI CPT 88309 • Pathology | $113 | $113 | $113 |
| Special stain group I for microorganisms CPT 88312 • Pathology | $21 | $21 | $21 |
| Special stain group II CPT 88313 • Pathology | $52 | $52 | $52 |
| Frozen section pathology first specimen CPT 88331 • Pathology | $48 | $48 | $48 |
| Frozen section pathology each additional CPT 88332 • Pathology | $24 | $24 | $24 |
| Immunohistochemistry each antibody CPT 88341 • Pathology | $68 | $68 | $68 |
| Immunohistochemistry first antibody CPT 88342 • Pathology | $77 | $77 | $77 |
| Morphometric analysis tumor quantitative CPT 88360 • Pathology | $93 | $93 | $93 |
| Microdissection manual CPT 88381 • Pathology | $160 | $160 | $160 |
| Hot or cold packs application CPT 97010 • Physical Therapy | $5 | $5 | $5 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $14 | $14 | $14 |
| Vasopneumatic device therapy CPT 97016 • Physical Therapy | $15 | $15 | $15 |
| Electrical stimulation attended each 15 minutes CPT 97032 • Physical Therapy | $16 | $16 | $16 |
| Ultrasound therapy each 15 minutes CPT 97035 • Physical Therapy | $12 | $12 | $12 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $28 | $28 | $28 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $29 | $29 | $29 |
| Gait training each 15 minutes CPT 97116 • Physical Therapy | $25 | $25 | $25 |