Service Area|Px Code|Procedure Description|Alternate CPT/HCPCS Code|Alternate Identification|Alternate Code by Location|Alternate Code by Department|Fee Schedule Group Name|Unit Price PEMBINA COUNTY MEDICAL CENTER|80300|DRUG SCREEN LIST A ANY NMBR NON TLC DEVICES|G0434,G0434,G0434,G0479,G0479,G0479|MEDICARE,TRICARE,VA,MEDICARE,TRICARE,VA|,,,,,|,,,,,|PC M/M HB CLINIC|76.00 PEMBINA COUNTY MEDICAL CENTER|PC80346|PC BENZODIAZEPINES;1-12|G6031,G6031,G6031|MEDICARE,TRICARE,VA|,,|,,|PC STANDARD FEE SCHEDULE|219.00 PEMBINA COUNTY MEDICAL CENTER|PC80361|PC OPIATES,1 OR MORE|G6056,G6056,G6056|MEDICARE,TRICARE,VA|,,|,,|PC STANDARD FEE SCHEDULE|231.00 PEMBINA COUNTY MEDICAL CENTER|4340015|HC DRIVING TRAINING|99999|MEDICARE|||PC STANDARD FEE SCHEDULE|0.00 PEMBINA COUNTY MEDICAL CENTER|4340016|HC DRIVING TRAINING|99999|MEDICARE|||PC STANDARD FEE SCHEDULE|0.00 PEMBINA COUNTY MEDICAL CENTER|4340017|HC DRIVING TRAINING|99999|MEDICARE|||PC STANDARD FEE SCHEDULE|0.00 PEMBINA COUNTY MEDICAL CENTER|G0008|ADMIN INFLUENZA VIRUS VAC|90471|TRICARE|||PC STANDARD FEE SCHEDULE|9.00 PEMBINA COUNTY MEDICAL CENTER|G0008|ADMIN INFLUENZA VIRUS VAC|90471|TRICARE|||PC NON M/M HB CLINIC|0.00 PEMBINA COUNTY MEDICAL CENTER|4200005|UNATTEND E-STIM|G0283,G0283,G0283,G0283,G0283|HUMANA VETERANS,MEDICARE,SANFORD,TRICARE,VA|,,,,|,,,,|PC STANDARD FEE SCHEDULE|54.00 PEMBINA COUNTY MEDICAL CENTER|4560004|URGENT CARE VISIT-EST PT LEVEL I|G0380,G0380,G0380,G0380,G0380,G0380,G0380,G0380,G0380,G0380,G0380,G0380,G0380,G0380,G0380,G0380,G0380,G0380,G0380|AETNA,BCMN,BCND,IHS,ITASCA,MEDICA,MEDICARE,MNBLUEPLUS,MNMA,NDMA,NDWC,PRIME WEST,SANFORD,TRICARE,UCARE,UHC,VA,WISC PS,WPS|,,,,,,,,,,,,,,,,,,|,,,,,,,,,,,,,,,,,,|PC STANDARD FEE SCHEDULE|39.00 PEMBINA COUNTY MEDICAL CENTER|6100034|MRA ABDOMEN|C8902,C8902|MEDICARE,UCARE|||PC STANDARD FEE SCHEDULE|2,245.00 PEMBINA COUNTY MEDICAL CENTER|7620000|HOURLY OBSERVATION|99218|NDMA|HEART OF AMERICA MEDICAL CENTER (HAMC) [22]||PC STANDARD FEE SCHEDULE|0.00 PEMBINA COUNTY MEDICAL CENTER|7710000|IMMUNIZATION ADMINISTRATION|90782|NDMA|FIRST CARE HEALTH CENTER [50]||PC STANDARD FEE SCHEDULE|20.99 PEMBINA COUNTY MEDICAL CENTER|7710000|IMMUNIZATION ADMINISTRATION|90782|NDMA|FIRST CARE HEALTH CENTER [50]||PC NON M/M HB CLINIC|0.00 PEMBINA COUNTY MEDICAL CENTER|7710001|HC IMMUNIZATION ADMIN EA ADDL|90782|NDMA|FIRST CARE HEALTH CENTER [50]||PC STANDARD FEE SCHEDULE|20.99 PEMBINA COUNTY MEDICAL CENTER|7710001|HC IMMUNIZATION ADMIN EA ADDL|90782|NDMA|FIRST CARE HEALTH CENTER [50]||PC NON M/M HB CLINIC|0.00 PEMBINA COUNTY MEDICAL CENTER|7710002|HC IMMUNIZATION ADMIN,ORAL/NASAL|90782|NDMA|FIRST CARE HEALTH CENTER [50]||PC STANDARD FEE SCHEDULE|20.99 PEMBINA COUNTY MEDICAL CENTER|7710002|HC IMMUNIZATION ADMIN,ORAL/NASAL|90782|NDMA|FIRST CARE HEALTH CENTER [50]||PC NON M/M HB CLINIC|0.00 PEMBINA COUNTY MEDICAL CENTER|4020075|US EXTREMITY|78070||FIRST CARE HEALTH CENTER [500000]||PC STANDARD FEE SCHEDULE|50.00