| Urinalysis nonautomated without microscopy CPT 81002 • Laboratory | $2 | $2 | $2 |
| Urinalysis automated without microscopy CPT 81003 • Laboratory | $2 | $2 | $2 |
| Fecal hemoglobin immunoassay CPT 82274 • Laboratory | $12 | $12 | $12 |
| Vitamin D 25-hydroxy CPT 82306 • Laboratory | $22 | $22 | $22 |
| Creatine kinase (CK) total CPT 82550 • Laboratory | $5 | $5 | $5 |
| Creatinine urine CPT 82570 • Laboratory | $4 | $4 | $4 |
| Ferritin CPT 82728 • Laboratory | $10 | $10 | $10 |
| IgA IgD IgG IgM each CPT 82784 • Laboratory | $7 | $7 | $7 |
| Glucose quantitative blood CPT 82947 • Laboratory | $3 | $3 | $3 |
| Hemoglobin A1c CPT 83036 • Laboratory | $7 | $7 | $7 |
| Iron serum CPT 83540 • Laboratory | $5 | $5 | $5 |
| Iron binding capacity CPT 83550 • Laboratory | $6 | $6 | $6 |
| Prostate specific antigen (PSA) CPT 84153 • Laboratory | $14 | $14 | $14 |
| Free thyroxine (T4) CPT 84439 • Laboratory | $7 | $7 | $7 |
| Thyroid stimulating hormone (TSH) CPT 84443 • Laboratory | $12 | $12 | $12 |
| 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 | $4 | $4 | $4 |
| Cyclic citrullinated peptide antibody CPT 86200 • Laboratory | $10 | $10 | $10 |
| Nuclear antigen antibody CPT 86235 • Laboratory | $13 | $13 | $13 |
| Heterophile antibodies screen CPT 86308 • Laboratory | $4 | $4 | $4 |
| TB skin test intradermal CPT 86580 • Laboratory | $5 | $5 | $5 |
| 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 | $26 | $26 | $26 |
| Gonorrhea nucleic acid amplification CPT 87591 • Laboratory | $26 | $26 | $26 |
| SARS-CoV-2 COVID-19 amplified probe CPT 87635 • Laboratory | $52 | $52 | $52 |
| Influenza virus assay with direct optical CPT 87804 • Laboratory | $18 | $18 | $18 |
| Strep A assay with optic observation CPT 87880 • Laboratory | $9 | $9 | $9 |
| Consultation office low complexity CPT 99243 • Office Visits | $0 | $0 | $0 |
| Consultation office high complexity CPT 99245 • Office Visits | $0 | $0 | $0 |
| Cytopathology concentration technique CPT 88108 • Pathology | $20 | $20 | $20 |
| Cytopathology cell enhancement technique CPT 88112 • Pathology | $30 | $30 | $30 |
| Cytopathology cervical/vaginal interpretation physician CPT 88141 • Pathology | $12 | $12 | $12 |
| Cytopathology cervical/vaginal manual screen CPT 88164 • Pathology | $8 | $8 | $8 |
| Cytopathology cervical/vaginal automated thin layer CPT 88175 • Pathology | $20 | $20 | $20 |
| Molecular cytogenetics DNA probe each CPT 88271 • Pathology | $16 | $16 | $16 |
| Cytogenetics molecular interpretation CPT 88291 • Pathology | $14 | $14 | $14 |
| Surgical pathology gross and micro exam level II CPT 88302 • Pathology | $20 | $20 | $20 |
| Surgical pathology gross and micro exam level III CPT 88304 • Pathology | $25 | $25 | $25 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $22 | $22 | $22 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $51 | $51 | $51 |
| Surgical pathology gross and micro exam level VI CPT 88309 • Pathology | $67 | $67 | $67 |
| Special stain group I for microorganisms CPT 88312 • Pathology | $16 | $16 | $16 |
| Special stain group II CPT 88313 • Pathology | $7 | $7 | $7 |
| Frozen section pathology first specimen CPT 88331 • Pathology | $48 | $48 | $48 |
| Frozen section pathology each additional CPT 88332 • Pathology | $5 | $5 | $5 |