| Ambulance Service - Emergency Transport, Advanced Life Support | $1,575 | N/A | $1,575 |
| Ambulance Service - Emergency Transport, Basic Life Support | $1,050 | N/A | $1,050 |
| Ambulance Service - Mileage Rate for Ambulance Transport | $32 | N/A | $32 |
| Ambulance Service - Non-Emergency Transport, Basic Life Support | $840 | N/A | $840 |
| Blood Test - Blood Glucose (Sugar) Level | $19 | N/A | $19 |
| Blood Test - Blood Glucose Control (Hemoglobin A1C) | $78 | N/A | $78 |
| Electrocardiogram (ECG or EKG), with Report and Interpretation | $1,084 | N/A | $1,084 |
| Lab Test - Detection for Strep (Streptococcus, group A) | $34 | N/A | $34 |
| Office Visit - Basic | $63 | N/A | $63 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 18-39 Years Old | $284 | N/A | $284 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 5-11 Years Old | $315 | N/A | $315 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 1-4 Years Old | $227 | N/A | $227 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 12-17 Years Old | $268 | N/A | $268 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 18-39 Years Old | $278 | N/A | $278 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 40-64 Years Old | $305 | N/A | $305 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 5-11 Years Old | $252 | N/A | $252 |
| Office Visit - Established Patient, High Complexity | $320 | N/A | $320 |
| Office Visit - Established Patient, Low Complexity | $142 | N/A | $142 |
| Office Visit - Established Patient, Moderate Complexity | $210 | N/A | $210 |
| Office Visit - New Patient, Low Complexity | $273 | N/A | $273 |
| Office Visit - New Patient, Minor | $221 | N/A | $221 |
| Office Visit - New Patient, Moderate Complexity | $378 | N/A | $378 |
| Urine Test - Urinalysis, Manual Test | $13 | N/A | $13 |
| Vaccine - Pneumococcal Conjugate for Injection into Muscle | $258 | N/A | $258 |
| Vaccine - Tetanus, Diptheria Toxoids, and Acellular Pertussis (Whooping Cough) for Injection into Muscle | $77 | N/A | $77 |
