| Developmental Screening | $25 | N/A | $25 |
| Office Visit - Basic | $108 | N/A | $108 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 1-4 Years Old | $364 | N/A | $364 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 12-17 Years Old | $334 | N/A | $334 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 5-11 Years Old | $395 | N/A | $395 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, Younger than 1 Year Old | $313 | N/A | $313 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 1-4 Years Old | $364 | N/A | $364 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 12-17 Years Old | $285 | N/A | $285 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 18-39 Years Old | $291 | N/A | $291 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, Younger than 1 Year Old | $313 | N/A | $313 |
| Office Visit - Established Patient, High Complexity | $353 | N/A | $353 |
| Office Visit - Established Patient, Low Complexity | $189 | N/A | $189 |
| Office Visit - Established Patient, Moderate Complexity | $264 | N/A | $264 |
| Vaccine - Tetanus, Diptheria Toxoids, and Acellular Pertussis (Whooping Cough) for Injection into Muscle | $88 | N/A | $88 |
