I had an ambulance ride earlier this year and got hit with a four figure bill despite having good insurance. I did some digging and found that the ambulance company has an agreement with the county granting them a monopoly on emergency ambulance service. The agreement includes a set fee schedule, but it is very aggressive such that almost all rides will cost over $2000. The company is of course out-of-network for most insurance providers and they bill people for the remaining balance after insurance pays (balance billing). I wouldn't be at all surprised if there was some form of kick-back going on between the company and the county government.