| Ambulance Service - Emergency Transport, Advanced Life Support | $1,575 | 0% | $1,575 |
| Ambulance Service - Emergency Transport, Basic Life Support | $1,050 | 0% | $1,050 |
| Ambulance Service - Mileage Rate for Ambulance Transport | $32 | 0% | $32 |
| Ambulance Service - Non-Emergency Transport, Basic Life Support | $840 | 0% | $840 |
| Blood Test - Blood Glucose Control (Hemoglobin A1C) | $78 | 0% | $78 |
| Blood Test - Clotting Time | $18 | 0% | $18 |
| Lab Test - Detection test for Influenza Virus | $40 | 0% | $40 |
| Office Visit - Basic | $84 | 0% | $84 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 18-39 Years Old | $284 | 0% | $284 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 40-64 Years Old | $326 | 0% | $326 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 5-11 Years Old | $315 | 0% | $315 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 1-4 Years Old | $227 | 0% | $227 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 12-17 Years Old | $268 | 0% | $268 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 18-39 Years Old | $252 | 0% | $252 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 40-64 Years Old | $273 | 0% | $273 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 5-11 Years Old | $227 | 0% | $227 |
| Office Visit - Established Patient, High Complexity | $294 | 0% | $294 |
| Office Visit - Established Patient, Low Complexity | $126 | 0% | $126 |
| Office Visit - Established Patient, Moderate Complexity | $189 | 0% | $189 |
| Office Visit - New Patient, Low Complexity | $252 | 0% | $252 |
| Office Visit - New Patient, Minor | $189 | 0% | $189 |
| Office Visit - New Patient, Moderate Complexity | $378 | 0% | $378 |
| Strep Test (Streptococcus, group A) | $32 | 0% | $32 |
| Urine Test - Urinalysis, Manual Test | $11 | 0% | $11 |
| Vaccine - Pneumococcal Conjugate for Injection into Muscle | $249 | 0% | $249 |
| Vaccine - Tetanus, Diptheria Toxoids, and Acellular Pertussis (Whooping Cough) for Injection into Muscle | $71 | 0% | $71 |
