Category Code Assignment Detail 2020 by Service Code...CCS/BETOS Fee Schedule Category and Code...
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CCS/BETOS Fee Schedule Category and Code Listing by Service Code Effective April 1, 2020 CCS/BETOS Category Service Code CCS_BETOS Description 173 10004 Other Diagnostic Procedures On Skin And Subcutaneous Tissue 173 10005 Other Diagnostic Procedures On Skin And Subcutaneous Tissue 173 10006 Other Diagnostic Procedures On Skin And Subcutaneous Tissue 173 10007 Other Diagnostic Procedures On Skin And Subcutaneous Tissue 173 10008 Other Diagnostic Procedures On Skin And Subcutaneous Tissue 173 10009 Other Diagnostic Procedures On Skin And Subcutaneous Tissue 173 10010 Other Diagnostic Procedures On Skin And Subcutaneous Tissue 173 10011 Other Diagnostic Procedures On Skin And Subcutaneous Tissue 173 10012 Other Diagnostic Procedures On Skin And Subcutaneous Tissue 173 10021 Other Diagnostic Procedures On Skin And Subcutaneous Tissue 174 10030 Other Non-Or Therapeutic Procedures On Skin And Breast 173 10035 Other Diagnostic Procedures On Skin And Subcutaneous Tissue 173 10036 Other Diagnostic Procedures On Skin And Subcutaneous Tissue 168 10040 Incision And Drainage, Skin And Subcutaneous Tissue 168 10060 Incision And Drainage, Skin And Subcutaneous Tissue 168 10061 Incision And Drainage, Skin And Subcutaneous Tissue 174 10080 Other Non-Or Therapeutic Procedures On Skin And Breast 174 10081 Other Non-Or Therapeutic Procedures On Skin And Breast 174 10120 Other Non-Or Therapeutic Procedures On Skin And Breast 174 10121 Other Non-Or Therapeutic Procedures On Skin And Breast 168 10140 Incision And Drainage, Skin And Subcutaneous Tissue 170 10160 Excision Of Skin Lesion 168 10180 Incision And Drainage, Skin And Subcutaneous Tissue 169 11000 Debridement Of Wound, Infection Or Burn 169 11001 Debridement Of Wound, Infection Or Burn 169 11004 Debridement Of Wound, Infection Or Burn 169 11005 Debridement Of Wound, Infection Or Burn 169 11006 Debridement Of Wound, Infection Or Burn 169 11008 Debridement Of Wound, Infection Or Burn 169 11010 Debridement Of Wound, Infection Or Burn 169 11011 Debridement Of Wound, Infection Or Burn 169 11012 Debridement Of Wound, Infection Or Burn 169 11042 Debridement Of Wound, Infection Or Burn 169 11043 Debridement Of Wound, Infection Or Burn 169 11044 Debridement Of Wound, Infection Or Burn 169 11045 Debridement Of Wound, Infection Or Burn 169 11046 Debridement Of Wound, Infection Or Burn 169 11047 Debridement Of Wound, Infection Or Burn 170 11055 Excision Of Skin Lesion 170 11056 Excision Of Skin Lesion 170 11057 Excision Of Skin Lesion 173 11102 Other Diagnostic Procedures On Skin And Subcutaneous Tissue 173 11103 Other Diagnostic Procedures On Skin And Subcutaneous Tissue 173 11104 Other Diagnostic Procedures On Skin And Subcutaneous Tissue 173 11105 Other Diagnostic Procedures On Skin And Subcutaneous Tissue 173 11106 Other Diagnostic Procedures On Skin And Subcutaneous Tissue 173 11107 Other Diagnostic Procedures On Skin And Subcutaneous Tissue 170 11200 Excision Of Skin Lesion 170 11201 Excision Of Skin Lesion 170 11300 Excision Of Skin Lesion 170 11301 Excision Of Skin Lesion 170 11302 Excision Of Skin Lesion 170 11303 Excision Of Skin Lesion 170 11305 Excision Of Skin Lesion 170 11306 Excision Of Skin Lesion 170 11307 Excision Of Skin Lesion 170 11308 Excision Of Skin Lesion 170 11310 Excision Of Skin Lesion 170 11311 Excision Of Skin Lesion 170 11312 Excision Of Skin Lesion 170 11313 Excision Of Skin Lesion 170 11400 Excision Of Skin Lesion 170 11401 Excision Of Skin Lesion 170 11402 Excision Of Skin Lesion 170 11403 Excision Of Skin Lesion 170 11404 Excision Of Skin Lesion 170 11406 Excision Of Skin Lesion 170 11420 Excision Of Skin Lesion > Service Categories have been created using a combination of Berenson-Eggers Type of Service (BETOS) and Clinical Classification Software (CCS) published by the Agency for Healthcare Research and Quality (AHRQ). > The presence of a Service Code on this list does not obligate us to make payment on a claim for a service or supply that is not covered under the terms of the applicable Benefit Plan. > Selected codes, shaded in this document for reference, are subject to reduction for "Mid-Level Providers" pursuant to contractual and/or policy specifications. Blue Cross NC Proprietary and Confidential 1 of 205
Transcript of Category Code Assignment Detail 2020 by Service Code...CCS/BETOS Fee Schedule Category and Code...
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
173 10004 Other Diagnostic Procedures On Skin And Subcutaneous Tissue
173 10005 Other Diagnostic Procedures On Skin And Subcutaneous Tissue
173 10006 Other Diagnostic Procedures On Skin And Subcutaneous Tissue
173 10007 Other Diagnostic Procedures On Skin And Subcutaneous Tissue
173 10008 Other Diagnostic Procedures On Skin And Subcutaneous Tissue
173 10009 Other Diagnostic Procedures On Skin And Subcutaneous Tissue
173 10010 Other Diagnostic Procedures On Skin And Subcutaneous Tissue
173 10011 Other Diagnostic Procedures On Skin And Subcutaneous Tissue
173 10012 Other Diagnostic Procedures On Skin And Subcutaneous Tissue
173 10021 Other Diagnostic Procedures On Skin And Subcutaneous Tissue
174 10030 Other Non-Or Therapeutic Procedures On Skin And Breast
173 10035 Other Diagnostic Procedures On Skin And Subcutaneous Tissue
173 10036 Other Diagnostic Procedures On Skin And Subcutaneous Tissue
168 10040 Incision And Drainage, Skin And Subcutaneous Tissue
168 10060 Incision And Drainage, Skin And Subcutaneous Tissue
168 10061 Incision And Drainage, Skin And Subcutaneous Tissue
174 10080 Other Non-Or Therapeutic Procedures On Skin And Breast
174 10081 Other Non-Or Therapeutic Procedures On Skin And Breast
174 10120 Other Non-Or Therapeutic Procedures On Skin And Breast
174 10121 Other Non-Or Therapeutic Procedures On Skin And Breast
168 10140 Incision And Drainage, Skin And Subcutaneous Tissue
170 10160 Excision Of Skin Lesion
168 10180 Incision And Drainage, Skin And Subcutaneous Tissue
169 11000 Debridement Of Wound, Infection Or Burn
169 11001 Debridement Of Wound, Infection Or Burn
169 11004 Debridement Of Wound, Infection Or Burn
169 11005 Debridement Of Wound, Infection Or Burn
169 11006 Debridement Of Wound, Infection Or Burn
169 11008 Debridement Of Wound, Infection Or Burn
169 11010 Debridement Of Wound, Infection Or Burn
169 11011 Debridement Of Wound, Infection Or Burn
169 11012 Debridement Of Wound, Infection Or Burn
169 11042 Debridement Of Wound, Infection Or Burn
169 11043 Debridement Of Wound, Infection Or Burn
169 11044 Debridement Of Wound, Infection Or Burn
169 11045 Debridement Of Wound, Infection Or Burn
169 11046 Debridement Of Wound, Infection Or Burn
169 11047 Debridement Of Wound, Infection Or Burn
170 11055 Excision Of Skin Lesion
170 11056 Excision Of Skin Lesion
170 11057 Excision Of Skin Lesion
173 11102 Other Diagnostic Procedures On Skin And Subcutaneous Tissue
173 11103 Other Diagnostic Procedures On Skin And Subcutaneous Tissue
173 11104 Other Diagnostic Procedures On Skin And Subcutaneous Tissue
173 11105 Other Diagnostic Procedures On Skin And Subcutaneous Tissue
173 11106 Other Diagnostic Procedures On Skin And Subcutaneous Tissue
173 11107 Other Diagnostic Procedures On Skin And Subcutaneous Tissue
170 11200 Excision Of Skin Lesion
170 11201 Excision Of Skin Lesion
170 11300 Excision Of Skin Lesion
170 11301 Excision Of Skin Lesion
170 11302 Excision Of Skin Lesion
170 11303 Excision Of Skin Lesion
170 11305 Excision Of Skin Lesion
170 11306 Excision Of Skin Lesion
170 11307 Excision Of Skin Lesion
170 11308 Excision Of Skin Lesion
170 11310 Excision Of Skin Lesion
170 11311 Excision Of Skin Lesion
170 11312 Excision Of Skin Lesion
170 11313 Excision Of Skin Lesion
170 11400 Excision Of Skin Lesion
170 11401 Excision Of Skin Lesion
170 11402 Excision Of Skin Lesion
170 11403 Excision Of Skin Lesion
170 11404 Excision Of Skin Lesion
170 11406 Excision Of Skin Lesion
170 11420 Excision Of Skin Lesion
> Service Categories have been created using a combination of Berenson-Eggers Type of Service (BETOS) and Clinical Classification Software (CCS) published by the Agency for
Healthcare Research and Quality (AHRQ).
> The presence of a Service Code on this list does not obligate us to make payment on a claim for a service or supply that is not covered under the terms of the applicable Benefit
Plan.
> Selected codes, shaded in this document for reference, are subject to reduction for "Mid-Level Providers" pursuant to contractual and/or policy specifications.
Blue Cross NC Proprietary and Confidential 1 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
170 11421 Excision Of Skin Lesion
170 11422 Excision Of Skin Lesion
170 11423 Excision Of Skin Lesion
170 11424 Excision Of Skin Lesion
170 11426 Excision Of Skin Lesion
170 11440 Excision Of Skin Lesion
170 11441 Excision Of Skin Lesion
170 11442 Excision Of Skin Lesion
170 11443 Excision Of Skin Lesion
170 11444 Excision Of Skin Lesion
170 11446 Excision Of Skin Lesion
170 11450 Excision Of Skin Lesion
170 11451 Excision Of Skin Lesion
170 11462 Excision Of Skin Lesion
170 11463 Excision Of Skin Lesion
170 11470 Excision Of Skin Lesion
170 11471 Excision Of Skin Lesion
170 11600 Excision Of Skin Lesion
170 11601 Excision Of Skin Lesion
170 11602 Excision Of Skin Lesion
170 11603 Excision Of Skin Lesion
170 11604 Excision Of Skin Lesion
170 11606 Excision Of Skin Lesion
170 11620 Excision Of Skin Lesion
170 11621 Excision Of Skin Lesion
170 11622 Excision Of Skin Lesion
170 11623 Excision Of Skin Lesion
170 11624 Excision Of Skin Lesion
170 11626 Excision Of Skin Lesion
170 11640 Excision Of Skin Lesion
170 11641 Excision Of Skin Lesion
170 11642 Excision Of Skin Lesion
170 11643 Excision Of Skin Lesion
170 11644 Excision Of Skin Lesion
170 11646 Excision Of Skin Lesion
174 11719 Other Non-Or Therapeutic Procedures On Skin And Breast
174 11720 Other Non-Or Therapeutic Procedures On Skin And Breast
174 11721 Other Non-Or Therapeutic Procedures On Skin And Breast
174 11730 Other Non-Or Therapeutic Procedures On Skin And Breast
174 11732 Other Non-Or Therapeutic Procedures On Skin And Breast
168 11740 Incision And Drainage, Skin And Subcutaneous Tissue
174 11750 Other Non-Or Therapeutic Procedures On Skin And Breast
173 11755 Other Diagnostic Procedures On Skin And Subcutaneous Tissue
175 11760 Other Or Therapeutic Procedures On Skin And Breast
175 11762 Other Or Therapeutic Procedures On Skin And Breast
174 11765 Other Non-Or Therapeutic Procedures On Skin And Breast
175 11770 Other Or Therapeutic Procedures On Skin And Breast
175 11771 Other Or Therapeutic Procedures On Skin And Breast
175 11772 Other Or Therapeutic Procedures On Skin And Breast
231 11900 Other Therapeutic Procedures
231 11901 Other Therapeutic Procedures
174 11920 Other Non-Or Therapeutic Procedures On Skin And Breast
174 11921 Other Non-Or Therapeutic Procedures On Skin And Breast
174 11922 Other Non-Or Therapeutic Procedures On Skin And Breast
174 11950 Other Non-Or Therapeutic Procedures On Skin And Breast
174 11951 Other Non-Or Therapeutic Procedures On Skin And Breast
174 11952 Other Non-Or Therapeutic Procedures On Skin And Breast
174 11954 Other Non-Or Therapeutic Procedures On Skin And Breast
175 11960 Other Or Therapeutic Procedures On Skin And Breast
175 11970 Other Or Therapeutic Procedures On Skin And Breast
175 11971 Other Or Therapeutic Procedures On Skin And Breast
174 11976 Other Non-Or Therapeutic Procedures On Skin And Breast
231 11980 Other Therapeutic Procedures
231 11981 Other Therapeutic Procedures
174 11982 Other Non-Or Therapeutic Procedures On Skin And Breast
231 11983 Other Therapeutic Procedures
171 12001 Suture Of Skin And Subcutaneous Tissue
171 12002 Suture Of Skin And Subcutaneous Tissue
171 12004 Suture Of Skin And Subcutaneous Tissue
171 12005 Suture Of Skin And Subcutaneous Tissue
171 12006 Suture Of Skin And Subcutaneous Tissue
171 12007 Suture Of Skin And Subcutaneous Tissue
171 12011 Suture Of Skin And Subcutaneous Tissue
171 12013 Suture Of Skin And Subcutaneous Tissue
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CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
171 12014 Suture Of Skin And Subcutaneous Tissue
171 12015 Suture Of Skin And Subcutaneous Tissue
171 12016 Suture Of Skin And Subcutaneous Tissue
171 12017 Suture Of Skin And Subcutaneous Tissue
171 12018 Suture Of Skin And Subcutaneous Tissue
171 12020 Suture Of Skin And Subcutaneous Tissue
171 12021 Suture Of Skin And Subcutaneous Tissue
171 12031 Suture Of Skin And Subcutaneous Tissue
171 12032 Suture Of Skin And Subcutaneous Tissue
171 12034 Suture Of Skin And Subcutaneous Tissue
171 12035 Suture Of Skin And Subcutaneous Tissue
171 12036 Suture Of Skin And Subcutaneous Tissue
171 12037 Suture Of Skin And Subcutaneous Tissue
171 12041 Suture Of Skin And Subcutaneous Tissue
171 12042 Suture Of Skin And Subcutaneous Tissue
171 12044 Suture Of Skin And Subcutaneous Tissue
171 12045 Suture Of Skin And Subcutaneous Tissue
171 12046 Suture Of Skin And Subcutaneous Tissue
171 12047 Suture Of Skin And Subcutaneous Tissue
171 12051 Suture Of Skin And Subcutaneous Tissue
171 12052 Suture Of Skin And Subcutaneous Tissue
171 12053 Suture Of Skin And Subcutaneous Tissue
171 12054 Suture Of Skin And Subcutaneous Tissue
171 12055 Suture Of Skin And Subcutaneous Tissue
171 12056 Suture Of Skin And Subcutaneous Tissue
171 12057 Suture Of Skin And Subcutaneous Tissue
171 13100 Suture Of Skin And Subcutaneous Tissue
171 13101 Suture Of Skin And Subcutaneous Tissue
171 13102 Suture Of Skin And Subcutaneous Tissue
171 13120 Suture Of Skin And Subcutaneous Tissue
171 13121 Suture Of Skin And Subcutaneous Tissue
171 13122 Suture Of Skin And Subcutaneous Tissue
171 13131 Suture Of Skin And Subcutaneous Tissue
171 13132 Suture Of Skin And Subcutaneous Tissue
171 13133 Suture Of Skin And Subcutaneous Tissue
220 13151 Ophthalmologic And Otologic Diagnosis And Treatment
220 13152 Ophthalmologic And Otologic Diagnosis And Treatment
220 13153 Ophthalmologic And Otologic Diagnosis And Treatment
171 13160 Suture Of Skin And Subcutaneous Tissue
172 14000 Skin Graft
172 14001 Skin Graft
172 14020 Skin Graft
172 14021 Skin Graft
172 14040 Skin Graft
172 14041 Skin Graft
172 14060 Skin Graft
172 14061 Skin Graft
172 14301 Skin Graft
172 14302 Skin Graft
172 14350 Skin Graft
172 15002 Skin Graft
172 15003 Skin Graft
172 15004 Skin Graft
172 15005 Skin Graft
172 15040 Skin Graft
172 15050 Skin Graft
172 15100 Skin Graft
172 15101 Skin Graft
172 15110 Skin Graft
172 15111 Skin Graft
172 15115 Skin Graft
172 15116 Skin Graft
172 15120 Skin Graft
172 15121 Skin Graft
172 15130 Skin Graft
172 15131 Skin Graft
172 15135 Skin Graft
172 15136 Skin Graft
172 15150 Skin Graft
172 15151 Skin Graft
172 15152 Skin Graft
172 15155 Skin Graft
172 15156 Skin Graft
172 15157 Skin Graft
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CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
172 15200 Skin Graft
172 15201 Skin Graft
172 15220 Skin Graft
172 15221 Skin Graft
172 15240 Skin Graft
172 15241 Skin Graft
172 15260 Skin Graft
172 15261 Skin Graft
172 15271 Skin Graft
172 15272 Skin Graft
172 15273 Skin Graft
172 15274 Skin Graft
172 15275 Skin Graft
172 15276 Skin Graft
172 15277 Skin Graft
172 15278 Skin Graft
172 15570 Skin Graft
172 15572 Skin Graft
172 15574 Skin Graft
172 15576 Skin Graft
172 15600 Skin Graft
172 15610 Skin Graft
172 15620 Skin Graft
172 15630 Skin Graft
172 15650 Skin Graft
172 15730 Skin Graft
172 15731 Skin Graft
172 15733 Skin Graft
172 15734 Skin Graft
172 15736 Skin Graft
172 15738 Skin Graft
175 15740 Other Or Therapeutic Procedures On Skin And Breast
9 15750 Other Or Therapeutic Nervous System Procedures
172 15756 Skin Graft
172 15757 Skin Graft
172 15758 Skin Graft
172 15760 Skin Graft
175 15769 Other Or Therapeutic Procedures On Skin And Breast
172 15770 Skin Graft
175 15771 Other Or Therapeutic Procedures On Skin And Breast
175 15772 Other Or Therapeutic Procedures On Skin And Breast
175 15773 Other Or Therapeutic Procedures On Skin And Breast
175 15774 Other Or Therapeutic Procedures On Skin And Breast
172 15775 Skin Graft
172 15776 Skin Graft
175 15777 Other Or Therapeutic Procedures On Skin And Breast
175 15780 Other Or Therapeutic Procedures On Skin And Breast
175 15781 Other Or Therapeutic Procedures On Skin And Breast
175 15782 Other Or Therapeutic Procedures On Skin And Breast
175 15783 Other Or Therapeutic Procedures On Skin And Breast
175 15786 Other Or Therapeutic Procedures On Skin And Breast
175 15787 Other Or Therapeutic Procedures On Skin And Breast
172 15788 Skin Graft
174 15789 Other Non-Or Therapeutic Procedures On Skin And Breast
174 15792 Other Non-Or Therapeutic Procedures On Skin And Breast
174 15793 Other Non-Or Therapeutic Procedures On Skin And Breast
175 15819 Other Or Therapeutic Procedures On Skin And Breast
220 15820 Ophthalmologic And Otologic Diagnosis And Treatment
220 15821 Ophthalmologic And Otologic Diagnosis And Treatment
220 15822 Ophthalmologic And Otologic Diagnosis And Treatment
220 15823 Ophthalmologic And Otologic Diagnosis And Treatment
175 15824 Other Or Therapeutic Procedures On Skin And Breast
175 15825 Other Or Therapeutic Procedures On Skin And Breast
175 15826 Other Or Therapeutic Procedures On Skin And Breast
175 15828 Other Or Therapeutic Procedures On Skin And Breast
175 15829 Other Or Therapeutic Procedures On Skin And Breast
175 15830 Other Or Therapeutic Procedures On Skin And Breast
175 15832 Other Or Therapeutic Procedures On Skin And Breast
175 15833 Other Or Therapeutic Procedures On Skin And Breast
175 15834 Other Or Therapeutic Procedures On Skin And Breast
175 15835 Other Or Therapeutic Procedures On Skin And Breast
175 15836 Other Or Therapeutic Procedures On Skin And Breast
175 15837 Other Or Therapeutic Procedures On Skin And Breast
175 15838 Other Or Therapeutic Procedures On Skin And Breast
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CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
175 15839 Other Or Therapeutic Procedures On Skin And Breast
172 15840 Skin Graft
172 15841 Skin Graft
172 15842 Skin Graft
172 15845 Skin Graft
175 15847 Other Or Therapeutic Procedures On Skin And Breast
231 15850 Other Therapeutic Procedures
231 15851 Other Therapeutic Procedures
214 15852 Traction, Splints, And Other Wound Care
175 15860 Other Or Therapeutic Procedures On Skin And Breast
175 15876 Other Or Therapeutic Procedures On Skin And Breast
175 15877 Other Or Therapeutic Procedures On Skin And Breast
175 15878 Other Or Therapeutic Procedures On Skin And Breast
175 15879 Other Or Therapeutic Procedures On Skin And Breast
142 15920 Partial Excision Bone
142 15922 Partial Excision Bone
170 15931 Excision Of Skin Lesion
142 15933 Partial Excision Bone
170 15934 Excision Of Skin Lesion
142 15935 Partial Excision Bone
170 15936 Excision Of Skin Lesion
142 15937 Partial Excision Bone
170 15940 Excision Of Skin Lesion
142 15941 Partial Excision Bone
170 15944 Excision Of Skin Lesion
142 15945 Partial Excision Bone
142 15946 Partial Excision Bone
170 15950 Excision Of Skin Lesion
142 15951 Partial Excision Bone
170 15952 Excision Of Skin Lesion
142 15953 Partial Excision Bone
170 15956 Excision Of Skin Lesion
142 15958 Partial Excision Bone
170 15999 Excision Of Skin Lesion
214 16000 Traction, Splints, And Other Wound Care
169 16020 Debridement Of Wound, Infection Or Burn
169 16025 Debridement Of Wound, Infection Or Burn
169 16030 Debridement Of Wound, Infection Or Burn
175 16035 Other Or Therapeutic Procedures On Skin And Breast
175 16036 Other Or Therapeutic Procedures On Skin And Breast
170 17000 Excision Of Skin Lesion
170 17003 Excision Of Skin Lesion
170 17004 Excision Of Skin Lesion
170 17106 Excision Of Skin Lesion
170 17107 Excision Of Skin Lesion
170 17108 Excision Of Skin Lesion
170 17110 Excision Of Skin Lesion
170 17111 Excision Of Skin Lesion
170 17250 Excision Of Skin Lesion
170 17260 Excision Of Skin Lesion
170 17261 Excision Of Skin Lesion
170 17262 Excision Of Skin Lesion
170 17263 Excision Of Skin Lesion
170 17264 Excision Of Skin Lesion
170 17266 Excision Of Skin Lesion
170 17270 Excision Of Skin Lesion
170 17271 Excision Of Skin Lesion
170 17272 Excision Of Skin Lesion
170 17273 Excision Of Skin Lesion
170 17274 Excision Of Skin Lesion
170 17276 Excision Of Skin Lesion
170 17280 Excision Of Skin Lesion
170 17281 Excision Of Skin Lesion
170 17282 Excision Of Skin Lesion
170 17283 Excision Of Skin Lesion
170 17284 Excision Of Skin Lesion
170 17286 Excision Of Skin Lesion
170 17311 Excision Of Skin Lesion
170 17312 Excision Of Skin Lesion
170 17313 Excision Of Skin Lesion
170 17314 Excision Of Skin Lesion
170 17315 Excision Of Skin Lesion
170 17340 Excision Of Skin Lesion
170 17360 Excision Of Skin Lesion
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CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
170 17380 Excision Of Skin Lesion
175 17999 Other Or Therapeutic Procedures On Skin And Breast
165 19000 Breast Biopsy And Other Diagnostic Procedures On Breast
165 19001 Breast Biopsy And Other Diagnostic Procedures On Breast
175 19020 Other Or Therapeutic Procedures On Skin And Breast
165 19030 Breast Biopsy And Other Diagnostic Procedures On Breast
165 19081 Breast Biopsy And Other Diagnostic Procedures On Breast
165 19082 Breast Biopsy And Other Diagnostic Procedures On Breast
165 19083 Breast Biopsy And Other Diagnostic Procedures On Breast
165 19084 Breast Biopsy And Other Diagnostic Procedures On Breast
165 19085 Breast Biopsy And Other Diagnostic Procedures On Breast
165 19086 Breast Biopsy And Other Diagnostic Procedures On Breast
165 19100 Breast Biopsy And Other Diagnostic Procedures On Breast
165 19101 Breast Biopsy And Other Diagnostic Procedures On Breast
132 19105 Other Or Therapeutic Procedures, Female Organs
174 19110 Other Non-Or Therapeutic Procedures On Skin And Breast
175 19112 Other Or Therapeutic Procedures On Skin And Breast
166 19120 Lumpectomy, Quadrantectomy Of Breast
166 19125 Lumpectomy, Quadrantectomy Of Breast
166 19126 Lumpectomy, Quadrantectomy Of Breast
165 19281 Breast Biopsy And Other Diagnostic Procedures On Breast
165 19282 Breast Biopsy And Other Diagnostic Procedures On Breast
165 19283 Breast Biopsy And Other Diagnostic Procedures On Breast
165 19284 Breast Biopsy And Other Diagnostic Procedures On Breast
165 19285 Breast Biopsy And Other Diagnostic Procedures On Breast
165 19286 Breast Biopsy And Other Diagnostic Procedures On Breast
165 19287 Breast Biopsy And Other Diagnostic Procedures On Breast
165 19288 Breast Biopsy And Other Diagnostic Procedures On Breast
166 19294 Lumpectomy, Quadrantectomy Of Breast
175 19296 Other Or Therapeutic Procedures On Skin And Breast
166 19297 Lumpectomy, Quadrantectomy Of Breast
175 19298 Other Or Therapeutic Procedures On Skin And Breast
167 19300 Mastectomy
166 19301 Lumpectomy, Quadrantectomy Of Breast
166 19302 Lumpectomy, Quadrantectomy Of Breast
167 19303 Mastectomy
167 19305 Mastectomy
167 19306 Mastectomy
167 19307 Mastectomy
175 19316 Other Or Therapeutic Procedures On Skin And Breast
175 19318 Other Or Therapeutic Procedures On Skin And Breast
175 19324 Other Or Therapeutic Procedures On Skin And Breast
175 19325 Other Or Therapeutic Procedures On Skin And Breast
175 19328 Other Or Therapeutic Procedures On Skin And Breast
175 19330 Other Or Therapeutic Procedures On Skin And Breast
175 19340 Other Or Therapeutic Procedures On Skin And Breast
175 19342 Other Or Therapeutic Procedures On Skin And Breast
175 19350 Other Or Therapeutic Procedures On Skin And Breast
175 19355 Other Or Therapeutic Procedures On Skin And Breast
175 19357 Other Or Therapeutic Procedures On Skin And Breast
175 19361 Other Or Therapeutic Procedures On Skin And Breast
175 19364 Other Or Therapeutic Procedures On Skin And Breast
175 19366 Other Or Therapeutic Procedures On Skin And Breast
175 19367 Other Or Therapeutic Procedures On Skin And Breast
175 19368 Other Or Therapeutic Procedures On Skin And Breast
175 19369 Other Or Therapeutic Procedures On Skin And Breast
175 19370 Other Or Therapeutic Procedures On Skin And Breast
175 19371 Other Or Therapeutic Procedures On Skin And Breast
175 19380 Other Or Therapeutic Procedures On Skin And Breast
174 19396 Other Non-Or Therapeutic Procedures On Skin And Breast
175 19499 Other Or Therapeutic Procedures On Skin And Breast
175 20100 Other Or Therapeutic Procedures On Skin And Breast
175 20101 Other Or Therapeutic Procedures On Skin And Breast
175 20102 Other Or Therapeutic Procedures On Skin And Breast
175 20103 Other Or Therapeutic Procedures On Skin And Breast
142 20150 Partial Excision Bone
159 20200 Other Diagnostic Procedures On Musculoskeletal System
159 20205 Other Diagnostic Procedures On Musculoskeletal System
159 20206 Other Diagnostic Procedures On Musculoskeletal System
159 20220 Other Diagnostic Procedures On Musculoskeletal System
159 20225 Other Diagnostic Procedures On Musculoskeletal System
159 20240 Other Diagnostic Procedures On Musculoskeletal System
159 20245 Other Diagnostic Procedures On Musculoskeletal System
159 20250 Other Diagnostic Procedures On Musculoskeletal System
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CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
159 20251 Other Diagnostic Procedures On Musculoskeletal System
156 20500 Injections And Aspirations Of Muscles, Tendons, Bursa, Joints And Soft Tissue
159 20501 Other Diagnostic Procedures On Musculoskeletal System
160 20520 Other Therapeutic Procedures On Muscles And Tendons
160 20525 Other Therapeutic Procedures On Muscles And Tendons
231 20526 Other Therapeutic Procedures
156 20527 Injections And Aspirations Of Muscles, Tendons, Bursa, Joints And Soft Tissue
156 20550 Injections And Aspirations Of Muscles, Tendons, Bursa, Joints And Soft Tissue
156 20551 Injections And Aspirations Of Muscles, Tendons, Bursa, Joints And Soft Tissue
156 20552 Injections And Aspirations Of Muscles, Tendons, Bursa, Joints And Soft Tissue
156 20553 Injections And Aspirations Of Muscles, Tendons, Bursa, Joints And Soft Tissue
164 20555 Other Or Therapeutic Procedures On Musculoskeletal System
213 20560 Physical Therapy Exercises, Manipulation, And Other Procedures
213 20561 Physical Therapy Exercises, Manipulation, And Other Procedures
155 20600 Arthrocentesis
155 20604 Arthrocentesis
155 20605 Arthrocentesis
155 20606 Arthrocentesis
155 20610 Arthrocentesis
155 20611 Arthrocentesis
156 20612 Injections And Aspirations Of Muscles, Tendons, Bursa, Joints And Soft Tissue
161 20615 Other Or Therapeutic Procedures On Bone
214 20650 Traction, Splints, And Other Wound Care
214 20660 Traction, Splints, And Other Wound Care
214 20661 Traction, Splints, And Other Wound Care
214 20662 Traction, Splints, And Other Wound Care
214 20663 Traction, Splints, And Other Wound Care
214 20664 Traction, Splints, And Other Wound Care
161 20665 Other Or Therapeutic Procedures On Bone
161 20670 Other Or Therapeutic Procedures On Bone
161 20680 Other Or Therapeutic Procedures On Bone
161 20690 Other Or Therapeutic Procedures On Bone
161 20692 Other Or Therapeutic Procedures On Bone
161 20693 Other Or Therapeutic Procedures On Bone
161 20694 Other Or Therapeutic Procedures On Bone
161 20696 Other Or Therapeutic Procedures On Bone
161 20697 Other Or Therapeutic Procedures On Bone
164 20700 Other Or Therapeutic Procedures On Musculoskeletal System
164 20701 Other Or Therapeutic Procedures On Musculoskeletal System
164 20702 Other Or Therapeutic Procedures On Musculoskeletal System
164 20703 Other Or Therapeutic Procedures On Musculoskeletal System
164 20704 Other Or Therapeutic Procedures On Musculoskeletal System
164 20705 Other Or Therapeutic Procedures On Musculoskeletal System
164 20802 Other Or Therapeutic Procedures On Musculoskeletal System
164 20805 Other Or Therapeutic Procedures On Musculoskeletal System
164 20808 Other Or Therapeutic Procedures On Musculoskeletal System
164 20816 Other Or Therapeutic Procedures On Musculoskeletal System
164 20822 Other Or Therapeutic Procedures On Musculoskeletal System
164 20824 Other Or Therapeutic Procedures On Musculoskeletal System
164 20827 Other Or Therapeutic Procedures On Musculoskeletal System
164 20838 Other Or Therapeutic Procedures On Musculoskeletal System
161 20900 Other Or Therapeutic Procedures On Bone
161 20902 Other Or Therapeutic Procedures On Bone
164 20910 Other Or Therapeutic Procedures On Musculoskeletal System
33 20912 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
160 20920 Other Therapeutic Procedures On Muscles And Tendons
160 20922 Other Therapeutic Procedures On Muscles And Tendons
160 20924 Other Therapeutic Procedures On Muscles And Tendons
161 20930 Other Or Therapeutic Procedures On Bone
161 20931 Other Or Therapeutic Procedures On Bone
161 20932 Other Or Therapeutic Procedures On Bone
161 20933 Other Or Therapeutic Procedures On Bone
161 20934 Other Or Therapeutic Procedures On Bone
161 20936 Other Or Therapeutic Procedures On Bone
161 20937 Other Or Therapeutic Procedures On Bone
161 20938 Other Or Therapeutic Procedures On Bone
161 20939 Other Or Therapeutic Procedures On Bone
159 20950 Other Diagnostic Procedures On Musculoskeletal System
161 20955 Other Or Therapeutic Procedures On Bone
161 20956 Other Or Therapeutic Procedures On Bone
161 20957 Other Or Therapeutic Procedures On Bone
161 20962 Other Or Therapeutic Procedures On Bone
161 20969 Other Or Therapeutic Procedures On Bone
161 20970 Other Or Therapeutic Procedures On Bone
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CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
161 20972 Other Or Therapeutic Procedures On Bone
161 20973 Other Or Therapeutic Procedures On Bone
163 20974 Other Non-Or Therapeutic Procedures On Musculoskeletal System
161 20975 Other Or Therapeutic Procedures On Bone
163 20979 Other Non-Or Therapeutic Procedures On Musculoskeletal System
163 20982 Other Non-Or Therapeutic Procedures On Musculoskeletal System
163 20983 Other Non-Or Therapeutic Procedures On Musculoskeletal System
164 20985 Other Or Therapeutic Procedures On Musculoskeletal System
164 20999 Other Or Therapeutic Procedures On Musculoskeletal System
162 21010 Other Or Therapeutic Procedures On Joints
170 21011 Excision Of Skin Lesion
170 21012 Excision Of Skin Lesion
160 21013 Other Therapeutic Procedures On Muscles And Tendons
160 21014 Other Therapeutic Procedures On Muscles And Tendons
160 21015 Other Therapeutic Procedures On Muscles And Tendons
160 21016 Other Therapeutic Procedures On Muscles And Tendons
142 21025 Partial Excision Bone
142 21026 Partial Excision Bone
142 21029 Partial Excision Bone
142 21030 Partial Excision Bone
142 21031 Partial Excision Bone
142 21032 Partial Excision Bone
142 21034 Partial Excision Bone
142 21040 Partial Excision Bone
142 21044 Partial Excision Bone
142 21045 Partial Excision Bone
142 21046 Partial Excision Bone
142 21047 Partial Excision Bone
142 21048 Partial Excision Bone
142 21049 Partial Excision Bone
142 21050 Partial Excision Bone
164 21060 Other Or Therapeutic Procedures On Musculoskeletal System
142 21070 Partial Excision Bone
162 21073 Other Or Therapeutic Procedures On Joints
32 21076 Other Non-Or Therapeutic Procedures On Nose, Mouth And Pharynx
32 21077 Other Non-Or Therapeutic Procedures On Nose, Mouth And Pharynx
32 21079 Other Non-Or Therapeutic Procedures On Nose, Mouth And Pharynx
32 21080 Other Non-Or Therapeutic Procedures On Nose, Mouth And Pharynx
32 21081 Other Non-Or Therapeutic Procedures On Nose, Mouth And Pharynx
32 21082 Other Non-Or Therapeutic Procedures On Nose, Mouth And Pharynx
32 21083 Other Non-Or Therapeutic Procedures On Nose, Mouth And Pharynx
32 21084 Other Non-Or Therapeutic Procedures On Nose, Mouth And Pharynx
32 21085 Other Non-Or Therapeutic Procedures On Nose, Mouth And Pharynx
32 21086 Other Non-Or Therapeutic Procedures On Nose, Mouth And Pharynx
32 21087 Other Non-Or Therapeutic Procedures On Nose, Mouth And Pharynx
32 21088 Other Non-Or Therapeutic Procedures On Nose, Mouth And Pharynx
32 21089 Other Non-Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 21100 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
29 21110 Oral And Dental Services
226 21116 Other Diagnostic Radiology And Related Techniques
161 21120 Other Or Therapeutic Procedures On Bone
161 21121 Other Or Therapeutic Procedures On Bone
161 21122 Other Or Therapeutic Procedures On Bone
161 21123 Other Or Therapeutic Procedures On Bone
161 21125 Other Or Therapeutic Procedures On Bone
161 21127 Other Or Therapeutic Procedures On Bone
161 21137 Other Or Therapeutic Procedures On Bone
161 21138 Other Or Therapeutic Procedures On Bone
161 21139 Other Or Therapeutic Procedures On Bone
161 21141 Other Or Therapeutic Procedures On Bone
161 21142 Other Or Therapeutic Procedures On Bone
161 21143 Other Or Therapeutic Procedures On Bone
161 21145 Other Or Therapeutic Procedures On Bone
161 21146 Other Or Therapeutic Procedures On Bone
161 21147 Other Or Therapeutic Procedures On Bone
161 21150 Other Or Therapeutic Procedures On Bone
161 21151 Other Or Therapeutic Procedures On Bone
161 21154 Other Or Therapeutic Procedures On Bone
161 21155 Other Or Therapeutic Procedures On Bone
161 21159 Other Or Therapeutic Procedures On Bone
161 21160 Other Or Therapeutic Procedures On Bone
161 21172 Other Or Therapeutic Procedures On Bone
161 21175 Other Or Therapeutic Procedures On Bone
161 21179 Other Or Therapeutic Procedures On Bone
Blue Cross NC Proprietary and Confidential 8 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
161 21180 Other Or Therapeutic Procedures On Bone
161 21181 Other Or Therapeutic Procedures On Bone
161 21182 Other Or Therapeutic Procedures On Bone
161 21183 Other Or Therapeutic Procedures On Bone
161 21184 Other Or Therapeutic Procedures On Bone
161 21188 Other Or Therapeutic Procedures On Bone
161 21193 Other Or Therapeutic Procedures On Bone
161 21194 Other Or Therapeutic Procedures On Bone
161 21195 Other Or Therapeutic Procedures On Bone
161 21196 Other Or Therapeutic Procedures On Bone
161 21198 Other Or Therapeutic Procedures On Bone
161 21199 Other Or Therapeutic Procedures On Bone
161 21206 Other Or Therapeutic Procedures On Bone
161 21208 Other Or Therapeutic Procedures On Bone
142 21209 Partial Excision Bone
161 21210 Other Or Therapeutic Procedures On Bone
161 21215 Other Or Therapeutic Procedures On Bone
164 21230 Other Or Therapeutic Procedures On Musculoskeletal System
164 21235 Other Or Therapeutic Procedures On Musculoskeletal System
154 21240 Arthroplasty Other Than Hip Or Knee
154 21242 Arthroplasty Other Than Hip Or Knee
154 21243 Arthroplasty Other Than Hip Or Knee
161 21244 Other Or Therapeutic Procedures On Bone
161 21245 Other Or Therapeutic Procedures On Bone
161 21246 Other Or Therapeutic Procedures On Bone
161 21247 Other Or Therapeutic Procedures On Bone
161 21248 Other Or Therapeutic Procedures On Bone
161 21249 Other Or Therapeutic Procedures On Bone
161 21255 Other Or Therapeutic Procedures On Bone
161 21256 Other Or Therapeutic Procedures On Bone
161 21260 Other Or Therapeutic Procedures On Bone
161 21261 Other Or Therapeutic Procedures On Bone
161 21263 Other Or Therapeutic Procedures On Bone
161 21267 Other Or Therapeutic Procedures On Bone
161 21268 Other Or Therapeutic Procedures On Bone
161 21270 Other Or Therapeutic Procedures On Bone
161 21275 Other Or Therapeutic Procedures On Bone
21 21280 Other Extraocular Muscle And Orbit Therapeutic Procedures
21 21282 Other Extraocular Muscle And Orbit Therapeutic Procedures
142 21295 Partial Excision Bone
142 21296 Partial Excision Bone
164 21299 Other Or Therapeutic Procedures On Musculoskeletal System
144 21310 Treatment, Facial Fracture Or Dislocation
144 21315 Treatment, Facial Fracture Or Dislocation
144 21320 Treatment, Facial Fracture Or Dislocation
144 21325 Treatment, Facial Fracture Or Dislocation
144 21330 Treatment, Facial Fracture Or Dislocation
144 21335 Treatment, Facial Fracture Or Dislocation
144 21336 Treatment, Facial Fracture Or Dislocation
144 21337 Treatment, Facial Fracture Or Dislocation
144 21338 Treatment, Facial Fracture Or Dislocation
144 21339 Treatment, Facial Fracture Or Dislocation
144 21340 Treatment, Facial Fracture Or Dislocation
144 21343 Treatment, Facial Fracture Or Dislocation
144 21344 Treatment, Facial Fracture Or Dislocation
144 21345 Treatment, Facial Fracture Or Dislocation
144 21346 Treatment, Facial Fracture Or Dislocation
144 21347 Treatment, Facial Fracture Or Dislocation
144 21348 Treatment, Facial Fracture Or Dislocation
144 21355 Treatment, Facial Fracture Or Dislocation
144 21356 Treatment, Facial Fracture Or Dislocation
144 21360 Treatment, Facial Fracture Or Dislocation
144 21365 Treatment, Facial Fracture Or Dislocation
144 21366 Treatment, Facial Fracture Or Dislocation
144 21385 Treatment, Facial Fracture Or Dislocation
144 21386 Treatment, Facial Fracture Or Dislocation
144 21387 Treatment, Facial Fracture Or Dislocation
144 21390 Treatment, Facial Fracture Or Dislocation
144 21395 Treatment, Facial Fracture Or Dislocation
144 21400 Treatment, Facial Fracture Or Dislocation
144 21401 Treatment, Facial Fracture Or Dislocation
144 21406 Treatment, Facial Fracture Or Dislocation
144 21407 Treatment, Facial Fracture Or Dislocation
144 21408 Treatment, Facial Fracture Or Dislocation
Blue Cross NC Proprietary and Confidential 9 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
144 21421 Treatment, Facial Fracture Or Dislocation
144 21422 Treatment, Facial Fracture Or Dislocation
144 21423 Treatment, Facial Fracture Or Dislocation
144 21431 Treatment, Facial Fracture Or Dislocation
144 21432 Treatment, Facial Fracture Or Dislocation
144 21433 Treatment, Facial Fracture Or Dislocation
144 21435 Treatment, Facial Fracture Or Dislocation
144 21436 Treatment, Facial Fracture Or Dislocation
144 21440 Treatment, Facial Fracture Or Dislocation
144 21445 Treatment, Facial Fracture Or Dislocation
144 21450 Treatment, Facial Fracture Or Dislocation
144 21451 Treatment, Facial Fracture Or Dislocation
144 21452 Treatment, Facial Fracture Or Dislocation
144 21453 Treatment, Facial Fracture Or Dislocation
144 21454 Treatment, Facial Fracture Or Dislocation
144 21461 Treatment, Facial Fracture Or Dislocation
144 21462 Treatment, Facial Fracture Or Dislocation
144 21465 Treatment, Facial Fracture Or Dislocation
144 21470 Treatment, Facial Fracture Or Dislocation
144 21480 Treatment, Facial Fracture Or Dislocation
144 21485 Treatment, Facial Fracture Or Dislocation
144 21490 Treatment, Facial Fracture Or Dislocation
29 21497 Oral And Dental Services
164 21499 Other Or Therapeutic Procedures On Musculoskeletal System
168 21501 Incision And Drainage, Skin And Subcutaneous Tissue
142 21502 Partial Excision Bone
161 21510 Other Or Therapeutic Procedures On Bone
159 21550 Other Diagnostic Procedures On Musculoskeletal System
170 21552 Excision Of Skin Lesion
160 21554 Other Therapeutic Procedures On Muscles And Tendons
170 21555 Excision Of Skin Lesion
160 21556 Other Therapeutic Procedures On Muscles And Tendons
160 21557 Other Therapeutic Procedures On Muscles And Tendons
160 21558 Other Therapeutic Procedures On Muscles And Tendons
142 21600 Partial Excision Bone
167 21601 Mastectomy
167 21602 Mastectomy
167 21603 Mastectomy
142 21610 Partial Excision Bone
142 21615 Partial Excision Bone
142 21616 Partial Excision Bone
142 21620 Partial Excision Bone
142 21627 Partial Excision Bone
142 21630 Partial Excision Bone
142 21632 Partial Excision Bone
164 21685 Other Or Therapeutic Procedures On Musculoskeletal System
160 21700 Other Therapeutic Procedures On Muscles And Tendons
142 21705 Partial Excision Bone
160 21720 Other Therapeutic Procedures On Muscles And Tendons
160 21725 Other Therapeutic Procedures On Muscles And Tendons
164 21740 Other Or Therapeutic Procedures On Musculoskeletal System
164 21742 Other Or Therapeutic Procedures On Musculoskeletal System
160 21743 Other Therapeutic Procedures On Muscles And Tendons
161 21750 Other Or Therapeutic Procedures On Bone
148 21811 Other Fracture And Dislocation Procedure
148 21812 Other Fracture And Dislocation Procedure
148 21813 Other Fracture And Dislocation Procedure
148 21820 Other Fracture And Dislocation Procedure
148 21825 Other Fracture And Dislocation Procedure
164 21899 Other Or Therapeutic Procedures On Musculoskeletal System
159 21920 Other Diagnostic Procedures On Musculoskeletal System
159 21925 Other Diagnostic Procedures On Musculoskeletal System
160 21930 Other Therapeutic Procedures On Muscles And Tendons
170 21931 Excision Of Skin Lesion
160 21932 Other Therapeutic Procedures On Muscles And Tendons
160 21933 Other Therapeutic Procedures On Muscles And Tendons
160 21935 Other Therapeutic Procedures On Muscles And Tendons
160 21936 Other Therapeutic Procedures On Muscles And Tendons
168 22010 Incision And Drainage, Skin And Subcutaneous Tissue
168 22015 Incision And Drainage, Skin And Subcutaneous Tissue
142 22100 Partial Excision Bone
142 22101 Partial Excision Bone
142 22102 Partial Excision Bone
142 22103 Partial Excision Bone
Blue Cross NC Proprietary and Confidential 10 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
142 22110 Partial Excision Bone
142 22112 Partial Excision Bone
142 22114 Partial Excision Bone
142 22116 Partial Excision Bone
142 22206 Partial Excision Bone
142 22207 Partial Excision Bone
142 22208 Partial Excision Bone
142 22210 Partial Excision Bone
142 22212 Partial Excision Bone
142 22214 Partial Excision Bone
142 22216 Partial Excision Bone
142 22220 Partial Excision Bone
142 22222 Partial Excision Bone
142 22224 Partial Excision Bone
142 22226 Partial Excision Bone
148 22310 Other Fracture And Dislocation Procedure
148 22315 Other Fracture And Dislocation Procedure
148 22318 Other Fracture And Dislocation Procedure
148 22319 Other Fracture And Dislocation Procedure
148 22325 Other Fracture And Dislocation Procedure
148 22326 Other Fracture And Dislocation Procedure
148 22327 Other Fracture And Dislocation Procedure
148 22328 Other Fracture And Dislocation Procedure
9 22505 Other Or Therapeutic Nervous System Procedures
148 22510 Other Fracture And Dislocation Procedure
148 22511 Other Fracture And Dislocation Procedure
148 22512 Other Fracture And Dislocation Procedure
148 22513 Other Fracture And Dislocation Procedure
148 22514 Other Fracture And Dislocation Procedure
148 22515 Other Fracture And Dislocation Procedure
9 22526 Other Or Therapeutic Nervous System Procedures
9 22527 Other Or Therapeutic Nervous System Procedures
158 22532 Spinal Fusion
158 22533 Spinal Fusion
158 22534 Spinal Fusion
158 22548 Spinal Fusion
158 22551 Spinal Fusion
158 22552 Spinal Fusion
158 22554 Spinal Fusion
158 22556 Spinal Fusion
158 22558 Spinal Fusion
158 22585 Spinal Fusion
158 22586 Spinal Fusion
158 22590 Spinal Fusion
158 22595 Spinal Fusion
158 22600 Spinal Fusion
158 22610 Spinal Fusion
158 22612 Spinal Fusion
158 22614 Spinal Fusion
158 22630 Spinal Fusion
158 22632 Spinal Fusion
158 22633 Spinal Fusion
158 22634 Spinal Fusion
158 22800 Spinal Fusion
158 22802 Spinal Fusion
158 22804 Spinal Fusion
158 22808 Spinal Fusion
158 22810 Spinal Fusion
158 22812 Spinal Fusion
142 22818 Partial Excision Bone
142 22819 Partial Excision Bone
161 22830 Other Or Therapeutic Procedures On Bone
158 22840 Spinal Fusion
158 22841 Spinal Fusion
158 22842 Spinal Fusion
158 22843 Spinal Fusion
158 22844 Spinal Fusion
158 22845 Spinal Fusion
158 22846 Spinal Fusion
158 22847 Spinal Fusion
158 22848 Spinal Fusion
158 22849 Spinal Fusion
158 22850 Spinal Fusion
158 22852 Spinal Fusion
Blue Cross NC Proprietary and Confidential 11 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
158 22853 Spinal Fusion
158 22854 Spinal Fusion
158 22855 Spinal Fusion
3 22856 Laminectomy, Excision Intervertebral Disc
158 22857 Spinal Fusion
3 22858 Laminectomy, Excision Intervertebral Disc
158 22859 Spinal Fusion
3 22861 Laminectomy, Excision Intervertebral Disc
158 22862 Spinal Fusion
3 22864 Laminectomy, Excision Intervertebral Disc
158 22865 Spinal Fusion
164 22867 Other Or Therapeutic Procedures On Musculoskeletal System
164 22868 Other Or Therapeutic Procedures On Musculoskeletal System
164 22869 Other Or Therapeutic Procedures On Musculoskeletal System
164 22870 Other Or Therapeutic Procedures On Musculoskeletal System
164 22899 Other Or Therapeutic Procedures On Musculoskeletal System
160 22900 Other Therapeutic Procedures On Muscles And Tendons
160 22901 Other Therapeutic Procedures On Muscles And Tendons
170 22902 Excision Of Skin Lesion
170 22903 Excision Of Skin Lesion
160 22904 Other Therapeutic Procedures On Muscles And Tendons
160 22905 Other Therapeutic Procedures On Muscles And Tendons
164 22999 Other Or Therapeutic Procedures On Musculoskeletal System
160 23000 Other Therapeutic Procedures On Muscles And Tendons
160 23020 Other Therapeutic Procedures On Muscles And Tendons
160 23030 Other Therapeutic Procedures On Muscles And Tendons
162 23031 Other Or Therapeutic Procedures On Joints
161 23035 Other Or Therapeutic Procedures On Bone
162 23040 Other Or Therapeutic Procedures On Joints
162 23044 Other Or Therapeutic Procedures On Joints
159 23065 Other Diagnostic Procedures On Musculoskeletal System
159 23066 Other Diagnostic Procedures On Musculoskeletal System
170 23071 Excision Of Skin Lesion
160 23073 Other Therapeutic Procedures On Muscles And Tendons
170 23075 Excision Of Skin Lesion
164 23076 Other Or Therapeutic Procedures On Musculoskeletal System
164 23077 Other Or Therapeutic Procedures On Musculoskeletal System
160 23078 Other Therapeutic Procedures On Muscles And Tendons
159 23100 Other Diagnostic Procedures On Musculoskeletal System
159 23101 Other Diagnostic Procedures On Musculoskeletal System
162 23105 Other Or Therapeutic Procedures On Joints
162 23106 Other Or Therapeutic Procedures On Joints
159 23107 Other Diagnostic Procedures On Musculoskeletal System
142 23120 Partial Excision Bone
142 23125 Partial Excision Bone
142 23130 Partial Excision Bone
142 23140 Partial Excision Bone
142 23145 Partial Excision Bone
142 23146 Partial Excision Bone
142 23150 Partial Excision Bone
142 23155 Partial Excision Bone
142 23156 Partial Excision Bone
161 23170 Other Or Therapeutic Procedures On Bone
161 23172 Other Or Therapeutic Procedures On Bone
161 23174 Other Or Therapeutic Procedures On Bone
142 23180 Partial Excision Bone
142 23182 Partial Excision Bone
142 23184 Partial Excision Bone
142 23190 Partial Excision Bone
142 23195 Partial Excision Bone
142 23200 Partial Excision Bone
142 23210 Partial Excision Bone
142 23220 Partial Excision Bone
174 23330 Other Non-Or Therapeutic Procedures On Skin And Breast
164 23333 Other Or Therapeutic Procedures On Musculoskeletal System
162 23334 Other Or Therapeutic Procedures On Joints
162 23335 Other Or Therapeutic Procedures On Joints
226 23350 Other Diagnostic Radiology And Related Techniques
160 23395 Other Therapeutic Procedures On Muscles And Tendons
160 23397 Other Therapeutic Procedures On Muscles And Tendons
161 23400 Other Or Therapeutic Procedures On Bone
160 23405 Other Therapeutic Procedures On Muscles And Tendons
160 23406 Other Therapeutic Procedures On Muscles And Tendons
160 23410 Other Therapeutic Procedures On Muscles And Tendons
Blue Cross NC Proprietary and Confidential 12 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
160 23412 Other Therapeutic Procedures On Muscles And Tendons
150 23415 Division Of Joint Capsule, Ligament Or Cartilage
154 23420 Arthroplasty Other Than Hip Or Knee
160 23430 Other Therapeutic Procedures On Muscles And Tendons
160 23440 Other Therapeutic Procedures On Muscles And Tendons
162 23450 Other Or Therapeutic Procedures On Joints
162 23455 Other Or Therapeutic Procedures On Joints
162 23460 Other Or Therapeutic Procedures On Joints
162 23462 Other Or Therapeutic Procedures On Joints
162 23465 Other Or Therapeutic Procedures On Joints
162 23466 Other Or Therapeutic Procedures On Joints
154 23470 Arthroplasty Other Than Hip Or Knee
154 23472 Arthroplasty Other Than Hip Or Knee
154 23473 Arthroplasty Other Than Hip Or Knee
154 23474 Arthroplasty Other Than Hip Or Knee
161 23480 Other Or Therapeutic Procedures On Bone
161 23485 Other Or Therapeutic Procedures On Bone
161 23490 Other Or Therapeutic Procedures On Bone
161 23491 Other Or Therapeutic Procedures On Bone
148 23500 Other Fracture And Dislocation Procedure
148 23505 Other Fracture And Dislocation Procedure
148 23515 Other Fracture And Dislocation Procedure
148 23520 Other Fracture And Dislocation Procedure
148 23525 Other Fracture And Dislocation Procedure
148 23530 Other Fracture And Dislocation Procedure
148 23532 Other Fracture And Dislocation Procedure
148 23540 Other Fracture And Dislocation Procedure
148 23545 Other Fracture And Dislocation Procedure
148 23550 Other Fracture And Dislocation Procedure
148 23552 Other Fracture And Dislocation Procedure
148 23570 Other Fracture And Dislocation Procedure
148 23575 Other Fracture And Dislocation Procedure
148 23585 Other Fracture And Dislocation Procedure
148 23600 Other Fracture And Dislocation Procedure
148 23605 Other Fracture And Dislocation Procedure
148 23615 Other Fracture And Dislocation Procedure
148 23616 Other Fracture And Dislocation Procedure
148 23620 Other Fracture And Dislocation Procedure
148 23625 Other Fracture And Dislocation Procedure
148 23630 Other Fracture And Dislocation Procedure
148 23650 Other Fracture And Dislocation Procedure
148 23655 Other Fracture And Dislocation Procedure
148 23660 Other Fracture And Dislocation Procedure
148 23665 Other Fracture And Dislocation Procedure
148 23670 Other Fracture And Dislocation Procedure
148 23675 Other Fracture And Dislocation Procedure
148 23680 Other Fracture And Dislocation Procedure
162 23700 Other Or Therapeutic Procedures On Joints
162 23800 Other Or Therapeutic Procedures On Joints
162 23802 Other Or Therapeutic Procedures On Joints
164 23900 Other Or Therapeutic Procedures On Musculoskeletal System
164 23920 Other Or Therapeutic Procedures On Musculoskeletal System
164 23921 Other Or Therapeutic Procedures On Musculoskeletal System
162 23929 Other Or Therapeutic Procedures On Joints
160 23930 Other Therapeutic Procedures On Muscles And Tendons
160 23931 Other Therapeutic Procedures On Muscles And Tendons
161 23935 Other Or Therapeutic Procedures On Bone
162 24000 Other Or Therapeutic Procedures On Joints
150 24006 Division Of Joint Capsule, Ligament Or Cartilage
159 24065 Other Diagnostic Procedures On Musculoskeletal System
159 24066 Other Diagnostic Procedures On Musculoskeletal System
170 24071 Excision Of Skin Lesion
160 24073 Other Therapeutic Procedures On Muscles And Tendons
170 24075 Excision Of Skin Lesion
160 24076 Other Therapeutic Procedures On Muscles And Tendons
160 24077 Other Therapeutic Procedures On Muscles And Tendons
160 24079 Other Therapeutic Procedures On Muscles And Tendons
159 24100 Other Diagnostic Procedures On Musculoskeletal System
159 24101 Other Diagnostic Procedures On Musculoskeletal System
150 24102 Division Of Joint Capsule, Ligament Or Cartilage
160 24105 Other Therapeutic Procedures On Muscles And Tendons
142 24110 Partial Excision Bone
142 24115 Partial Excision Bone
142 24116 Partial Excision Bone
Blue Cross NC Proprietary and Confidential 13 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
142 24120 Partial Excision Bone
142 24125 Partial Excision Bone
142 24126 Partial Excision Bone
142 24130 Partial Excision Bone
161 24134 Other Or Therapeutic Procedures On Bone
161 24136 Other Or Therapeutic Procedures On Bone
161 24138 Other Or Therapeutic Procedures On Bone
142 24140 Partial Excision Bone
142 24145 Partial Excision Bone
142 24147 Partial Excision Bone
142 24149 Partial Excision Bone
142 24150 Partial Excision Bone
142 24152 Partial Excision Bone
162 24155 Other Or Therapeutic Procedures On Joints
148 24160 Other Fracture And Dislocation Procedure
145 24164 Treatment, Fracture Or Dislocation Of Radius And Ulna
174 24200 Other Non-Or Therapeutic Procedures On Skin And Breast
160 24201 Other Therapeutic Procedures On Muscles And Tendons
226 24220 Other Diagnostic Radiology And Related Techniques
162 24300 Other Or Therapeutic Procedures On Joints
160 24301 Other Therapeutic Procedures On Muscles And Tendons
160 24305 Other Therapeutic Procedures On Muscles And Tendons
160 24310 Other Therapeutic Procedures On Muscles And Tendons
160 24320 Other Therapeutic Procedures On Muscles And Tendons
160 24330 Other Therapeutic Procedures On Muscles And Tendons
160 24331 Other Therapeutic Procedures On Muscles And Tendons
160 24332 Other Therapeutic Procedures On Muscles And Tendons
160 24340 Other Therapeutic Procedures On Muscles And Tendons
160 24341 Other Therapeutic Procedures On Muscles And Tendons
160 24342 Other Therapeutic Procedures On Muscles And Tendons
162 24343 Other Or Therapeutic Procedures On Joints
162 24344 Other Or Therapeutic Procedures On Joints
162 24345 Other Or Therapeutic Procedures On Joints
162 24346 Other Or Therapeutic Procedures On Joints
162 24357 Other Or Therapeutic Procedures On Joints
162 24358 Other Or Therapeutic Procedures On Joints
162 24359 Other Or Therapeutic Procedures On Joints
154 24360 Arthroplasty Other Than Hip Or Knee
154 24361 Arthroplasty Other Than Hip Or Knee
154 24362 Arthroplasty Other Than Hip Or Knee
154 24363 Arthroplasty Other Than Hip Or Knee
154 24365 Arthroplasty Other Than Hip Or Knee
154 24366 Arthroplasty Other Than Hip Or Knee
154 24370 Arthroplasty Other Than Hip Or Knee
154 24371 Arthroplasty Other Than Hip Or Knee
161 24400 Other Or Therapeutic Procedures On Bone
161 24410 Other Or Therapeutic Procedures On Bone
161 24420 Other Or Therapeutic Procedures On Bone
148 24430 Other Fracture And Dislocation Procedure
161 24435 Other Or Therapeutic Procedures On Bone
161 24470 Other Or Therapeutic Procedures On Bone
160 24495 Other Therapeutic Procedures On Muscles And Tendons
148 24498 Other Fracture And Dislocation Procedure
148 24500 Other Fracture And Dislocation Procedure
148 24505 Other Fracture And Dislocation Procedure
148 24515 Other Fracture And Dislocation Procedure
148 24516 Other Fracture And Dislocation Procedure
148 24530 Other Fracture And Dislocation Procedure
148 24535 Other Fracture And Dislocation Procedure
148 24538 Other Fracture And Dislocation Procedure
148 24545 Other Fracture And Dislocation Procedure
148 24546 Other Fracture And Dislocation Procedure
148 24560 Other Fracture And Dislocation Procedure
148 24565 Other Fracture And Dislocation Procedure
148 24566 Other Fracture And Dislocation Procedure
148 24575 Other Fracture And Dislocation Procedure
148 24576 Other Fracture And Dislocation Procedure
148 24577 Other Fracture And Dislocation Procedure
148 24579 Other Fracture And Dislocation Procedure
148 24582 Other Fracture And Dislocation Procedure
145 24586 Treatment, Fracture Or Dislocation Of Radius And Ulna
145 24587 Treatment, Fracture Or Dislocation Of Radius And Ulna
145 24600 Treatment, Fracture Or Dislocation Of Radius And Ulna
145 24605 Treatment, Fracture Or Dislocation Of Radius And Ulna
Blue Cross NC Proprietary and Confidential 14 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
145 24615 Treatment, Fracture Or Dislocation Of Radius And Ulna
145 24620 Treatment, Fracture Or Dislocation Of Radius And Ulna
145 24635 Treatment, Fracture Or Dislocation Of Radius And Ulna
145 24640 Treatment, Fracture Or Dislocation Of Radius And Ulna
145 24650 Treatment, Fracture Or Dislocation Of Radius And Ulna
145 24655 Treatment, Fracture Or Dislocation Of Radius And Ulna
145 24665 Treatment, Fracture Or Dislocation Of Radius And Ulna
145 24666 Treatment, Fracture Or Dislocation Of Radius And Ulna
145 24670 Treatment, Fracture Or Dislocation Of Radius And Ulna
145 24675 Treatment, Fracture Or Dislocation Of Radius And Ulna
145 24685 Treatment, Fracture Or Dislocation Of Radius And Ulna
162 24800 Other Or Therapeutic Procedures On Joints
162 24802 Other Or Therapeutic Procedures On Joints
164 24900 Other Or Therapeutic Procedures On Musculoskeletal System
164 24920 Other Or Therapeutic Procedures On Musculoskeletal System
164 24925 Other Or Therapeutic Procedures On Musculoskeletal System
164 24930 Other Or Therapeutic Procedures On Musculoskeletal System
164 24931 Other Or Therapeutic Procedures On Musculoskeletal System
161 24935 Other Or Therapeutic Procedures On Bone
164 24940 Other Or Therapeutic Procedures On Musculoskeletal System
164 24999 Other Or Therapeutic Procedures On Musculoskeletal System
160 25000 Other Therapeutic Procedures On Muscles And Tendons
160 25001 Other Therapeutic Procedures On Muscles And Tendons
160 25020 Other Therapeutic Procedures On Muscles And Tendons
160 25023 Other Therapeutic Procedures On Muscles And Tendons
160 25024 Other Therapeutic Procedures On Muscles And Tendons
160 25025 Other Therapeutic Procedures On Muscles And Tendons
160 25028 Other Therapeutic Procedures On Muscles And Tendons
160 25031 Other Therapeutic Procedures On Muscles And Tendons
161 25035 Other Or Therapeutic Procedures On Bone
159 25040 Other Diagnostic Procedures On Musculoskeletal System
159 25065 Other Diagnostic Procedures On Musculoskeletal System
159 25066 Other Diagnostic Procedures On Musculoskeletal System
170 25071 Excision Of Skin Lesion
160 25073 Other Therapeutic Procedures On Muscles And Tendons
170 25075 Excision Of Skin Lesion
160 25076 Other Therapeutic Procedures On Muscles And Tendons
160 25077 Other Therapeutic Procedures On Muscles And Tendons
160 25078 Other Therapeutic Procedures On Muscles And Tendons
150 25085 Division Of Joint Capsule, Ligament Or Cartilage
159 25100 Other Diagnostic Procedures On Musculoskeletal System
159 25101 Other Diagnostic Procedures On Musculoskeletal System
162 25105 Other Or Therapeutic Procedures On Joints
162 25107 Other Or Therapeutic Procedures On Joints
160 25109 Other Therapeutic Procedures On Muscles And Tendons
160 25110 Other Therapeutic Procedures On Muscles And Tendons
160 25111 Other Therapeutic Procedures On Muscles And Tendons
160 25112 Other Therapeutic Procedures On Muscles And Tendons
160 25115 Other Therapeutic Procedures On Muscles And Tendons
160 25116 Other Therapeutic Procedures On Muscles And Tendons
162 25118 Other Or Therapeutic Procedures On Joints
142 25119 Partial Excision Bone
142 25120 Partial Excision Bone
142 25125 Partial Excision Bone
142 25126 Partial Excision Bone
142 25130 Partial Excision Bone
142 25135 Partial Excision Bone
142 25136 Partial Excision Bone
161 25145 Other Or Therapeutic Procedures On Bone
142 25150 Partial Excision Bone
142 25151 Partial Excision Bone
142 25170 Partial Excision Bone
142 25210 Partial Excision Bone
142 25215 Partial Excision Bone
142 25230 Partial Excision Bone
142 25240 Partial Excision Bone
226 25246 Other Diagnostic Radiology And Related Techniques
160 25248 Other Therapeutic Procedures On Muscles And Tendons
162 25250 Other Or Therapeutic Procedures On Joints
162 25251 Other Or Therapeutic Procedures On Joints
162 25259 Other Or Therapeutic Procedures On Joints
160 25260 Other Therapeutic Procedures On Muscles And Tendons
160 25263 Other Therapeutic Procedures On Muscles And Tendons
160 25265 Other Therapeutic Procedures On Muscles And Tendons
Blue Cross NC Proprietary and Confidential 15 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
160 25270 Other Therapeutic Procedures On Muscles And Tendons
160 25272 Other Therapeutic Procedures On Muscles And Tendons
160 25274 Other Therapeutic Procedures On Muscles And Tendons
160 25275 Other Therapeutic Procedures On Muscles And Tendons
160 25280 Other Therapeutic Procedures On Muscles And Tendons
160 25290 Other Therapeutic Procedures On Muscles And Tendons
160 25295 Other Therapeutic Procedures On Muscles And Tendons
160 25300 Other Therapeutic Procedures On Muscles And Tendons
160 25301 Other Therapeutic Procedures On Muscles And Tendons
160 25310 Other Therapeutic Procedures On Muscles And Tendons
160 25312 Other Therapeutic Procedures On Muscles And Tendons
160 25315 Other Therapeutic Procedures On Muscles And Tendons
160 25316 Other Therapeutic Procedures On Muscles And Tendons
162 25320 Other Or Therapeutic Procedures On Joints
154 25332 Arthroplasty Other Than Hip Or Knee
162 25335 Other Or Therapeutic Procedures On Joints
162 25337 Other Or Therapeutic Procedures On Joints
161 25350 Other Or Therapeutic Procedures On Bone
161 25355 Other Or Therapeutic Procedures On Bone
161 25360 Other Or Therapeutic Procedures On Bone
161 25365 Other Or Therapeutic Procedures On Bone
161 25370 Other Or Therapeutic Procedures On Bone
161 25375 Other Or Therapeutic Procedures On Bone
161 25390 Other Or Therapeutic Procedures On Bone
161 25391 Other Or Therapeutic Procedures On Bone
161 25392 Other Or Therapeutic Procedures On Bone
161 25393 Other Or Therapeutic Procedures On Bone
161 25394 Other Or Therapeutic Procedures On Bone
145 25400 Treatment, Fracture Or Dislocation Of Radius And Ulna
145 25405 Treatment, Fracture Or Dislocation Of Radius And Ulna
145 25415 Treatment, Fracture Or Dislocation Of Radius And Ulna
145 25420 Treatment, Fracture Or Dislocation Of Radius And Ulna
161 25425 Other Or Therapeutic Procedures On Bone
161 25426 Other Or Therapeutic Procedures On Bone
161 25430 Other Or Therapeutic Procedures On Bone
148 25431 Other Fracture And Dislocation Procedure
148 25440 Other Fracture And Dislocation Procedure
154 25441 Arthroplasty Other Than Hip Or Knee
154 25442 Arthroplasty Other Than Hip Or Knee
154 25443 Arthroplasty Other Than Hip Or Knee
154 25444 Arthroplasty Other Than Hip Or Knee
154 25445 Arthroplasty Other Than Hip Or Knee
154 25446 Arthroplasty Other Than Hip Or Knee
154 25447 Arthroplasty Other Than Hip Or Knee
154 25449 Arthroplasty Other Than Hip Or Knee
161 25450 Other Or Therapeutic Procedures On Bone
161 25455 Other Or Therapeutic Procedures On Bone
161 25490 Other Or Therapeutic Procedures On Bone
161 25491 Other Or Therapeutic Procedures On Bone
161 25492 Other Or Therapeutic Procedures On Bone
145 25500 Treatment, Fracture Or Dislocation Of Radius And Ulna
145 25505 Treatment, Fracture Or Dislocation Of Radius And Ulna
145 25515 Treatment, Fracture Or Dislocation Of Radius And Ulna
145 25520 Treatment, Fracture Or Dislocation Of Radius And Ulna
145 25525 Treatment, Fracture Or Dislocation Of Radius And Ulna
145 25526 Treatment, Fracture Or Dislocation Of Radius And Ulna
145 25530 Treatment, Fracture Or Dislocation Of Radius And Ulna
145 25535 Treatment, Fracture Or Dislocation Of Radius And Ulna
145 25545 Treatment, Fracture Or Dislocation Of Radius And Ulna
145 25560 Treatment, Fracture Or Dislocation Of Radius And Ulna
145 25565 Treatment, Fracture Or Dislocation Of Radius And Ulna
145 25574 Treatment, Fracture Or Dislocation Of Radius And Ulna
145 25575 Treatment, Fracture Or Dislocation Of Radius And Ulna
145 25600 Treatment, Fracture Or Dislocation Of Radius And Ulna
145 25605 Treatment, Fracture Or Dislocation Of Radius And Ulna
145 25606 Treatment, Fracture Or Dislocation Of Radius And Ulna
145 25607 Treatment, Fracture Or Dislocation Of Radius And Ulna
145 25608 Treatment, Fracture Or Dislocation Of Radius And Ulna
145 25609 Treatment, Fracture Or Dislocation Of Radius And Ulna
148 25622 Other Fracture And Dislocation Procedure
148 25624 Other Fracture And Dislocation Procedure
148 25628 Other Fracture And Dislocation Procedure
148 25630 Other Fracture And Dislocation Procedure
148 25635 Other Fracture And Dislocation Procedure
Blue Cross NC Proprietary and Confidential 16 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
148 25645 Other Fracture And Dislocation Procedure
145 25650 Treatment, Fracture Or Dislocation Of Radius And Ulna
145 25651 Treatment, Fracture Or Dislocation Of Radius And Ulna
145 25652 Treatment, Fracture Or Dislocation Of Radius And Ulna
145 25660 Treatment, Fracture Or Dislocation Of Radius And Ulna
148 25670 Other Fracture And Dislocation Procedure
145 25671 Treatment, Fracture Or Dislocation Of Radius And Ulna
145 25675 Treatment, Fracture Or Dislocation Of Radius And Ulna
145 25676 Treatment, Fracture Or Dislocation Of Radius And Ulna
148 25680 Other Fracture And Dislocation Procedure
148 25685 Other Fracture And Dislocation Procedure
148 25690 Other Fracture And Dislocation Procedure
148 25695 Other Fracture And Dislocation Procedure
162 25800 Other Or Therapeutic Procedures On Joints
162 25805 Other Or Therapeutic Procedures On Joints
162 25810 Other Or Therapeutic Procedures On Joints
162 25820 Other Or Therapeutic Procedures On Joints
162 25825 Other Or Therapeutic Procedures On Joints
162 25830 Other Or Therapeutic Procedures On Joints
164 25900 Other Or Therapeutic Procedures On Musculoskeletal System
164 25905 Other Or Therapeutic Procedures On Musculoskeletal System
164 25907 Other Or Therapeutic Procedures On Musculoskeletal System
164 25909 Other Or Therapeutic Procedures On Musculoskeletal System
164 25915 Other Or Therapeutic Procedures On Musculoskeletal System
164 25920 Other Or Therapeutic Procedures On Musculoskeletal System
164 25922 Other Or Therapeutic Procedures On Musculoskeletal System
164 25924 Other Or Therapeutic Procedures On Musculoskeletal System
164 25927 Other Or Therapeutic Procedures On Musculoskeletal System
164 25929 Other Or Therapeutic Procedures On Musculoskeletal System
164 25931 Other Or Therapeutic Procedures On Musculoskeletal System
164 25999 Other Or Therapeutic Procedures On Musculoskeletal System
168 26010 Incision And Drainage, Skin And Subcutaneous Tissue
168 26011 Incision And Drainage, Skin And Subcutaneous Tissue
160 26020 Other Therapeutic Procedures On Muscles And Tendons
160 26025 Other Therapeutic Procedures On Muscles And Tendons
160 26030 Other Therapeutic Procedures On Muscles And Tendons
161 26034 Other Or Therapeutic Procedures On Bone
160 26035 Other Therapeutic Procedures On Muscles And Tendons
160 26037 Other Therapeutic Procedures On Muscles And Tendons
160 26040 Other Therapeutic Procedures On Muscles And Tendons
160 26045 Other Therapeutic Procedures On Muscles And Tendons
160 26055 Other Therapeutic Procedures On Muscles And Tendons
160 26060 Other Therapeutic Procedures On Muscles And Tendons
162 26070 Other Or Therapeutic Procedures On Joints
162 26075 Other Or Therapeutic Procedures On Joints
162 26080 Other Or Therapeutic Procedures On Joints
159 26100 Other Diagnostic Procedures On Musculoskeletal System
159 26105 Other Diagnostic Procedures On Musculoskeletal System
159 26110 Other Diagnostic Procedures On Musculoskeletal System
170 26111 Excision Of Skin Lesion
160 26113 Other Therapeutic Procedures On Muscles And Tendons
170 26115 Excision Of Skin Lesion
160 26116 Other Therapeutic Procedures On Muscles And Tendons
160 26117 Other Therapeutic Procedures On Muscles And Tendons
160 26118 Other Therapeutic Procedures On Muscles And Tendons
160 26121 Other Therapeutic Procedures On Muscles And Tendons
160 26123 Other Therapeutic Procedures On Muscles And Tendons
160 26125 Other Therapeutic Procedures On Muscles And Tendons
162 26130 Other Or Therapeutic Procedures On Joints
162 26135 Other Or Therapeutic Procedures On Joints
162 26140 Other Or Therapeutic Procedures On Joints
162 26145 Other Or Therapeutic Procedures On Joints
160 26160 Other Therapeutic Procedures On Muscles And Tendons
160 26170 Other Therapeutic Procedures On Muscles And Tendons
160 26180 Other Therapeutic Procedures On Muscles And Tendons
161 26185 Other Or Therapeutic Procedures On Bone
142 26200 Partial Excision Bone
142 26205 Partial Excision Bone
142 26210 Partial Excision Bone
142 26215 Partial Excision Bone
142 26230 Partial Excision Bone
142 26235 Partial Excision Bone
142 26236 Partial Excision Bone
142 26250 Partial Excision Bone
Blue Cross NC Proprietary and Confidential 17 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
142 26260 Partial Excision Bone
142 26262 Partial Excision Bone
164 26320 Other Or Therapeutic Procedures On Musculoskeletal System
162 26340 Other Or Therapeutic Procedures On Joints
163 26341 Other Non-Or Therapeutic Procedures On Musculoskeletal System
160 26350 Other Therapeutic Procedures On Muscles And Tendons
160 26352 Other Therapeutic Procedures On Muscles And Tendons
160 26356 Other Therapeutic Procedures On Muscles And Tendons
160 26357 Other Therapeutic Procedures On Muscles And Tendons
160 26358 Other Therapeutic Procedures On Muscles And Tendons
160 26370 Other Therapeutic Procedures On Muscles And Tendons
160 26372 Other Therapeutic Procedures On Muscles And Tendons
160 26373 Other Therapeutic Procedures On Muscles And Tendons
160 26390 Other Therapeutic Procedures On Muscles And Tendons
160 26392 Other Therapeutic Procedures On Muscles And Tendons
160 26410 Other Therapeutic Procedures On Muscles And Tendons
160 26412 Other Therapeutic Procedures On Muscles And Tendons
160 26415 Other Therapeutic Procedures On Muscles And Tendons
160 26416 Other Therapeutic Procedures On Muscles And Tendons
160 26418 Other Therapeutic Procedures On Muscles And Tendons
160 26420 Other Therapeutic Procedures On Muscles And Tendons
160 26426 Other Therapeutic Procedures On Muscles And Tendons
160 26428 Other Therapeutic Procedures On Muscles And Tendons
160 26432 Other Therapeutic Procedures On Muscles And Tendons
160 26433 Other Therapeutic Procedures On Muscles And Tendons
160 26434 Other Therapeutic Procedures On Muscles And Tendons
160 26437 Other Therapeutic Procedures On Muscles And Tendons
160 26440 Other Therapeutic Procedures On Muscles And Tendons
160 26442 Other Therapeutic Procedures On Muscles And Tendons
160 26445 Other Therapeutic Procedures On Muscles And Tendons
160 26449 Other Therapeutic Procedures On Muscles And Tendons
160 26450 Other Therapeutic Procedures On Muscles And Tendons
160 26455 Other Therapeutic Procedures On Muscles And Tendons
160 26460 Other Therapeutic Procedures On Muscles And Tendons
160 26471 Other Therapeutic Procedures On Muscles And Tendons
160 26474 Other Therapeutic Procedures On Muscles And Tendons
160 26476 Other Therapeutic Procedures On Muscles And Tendons
160 26477 Other Therapeutic Procedures On Muscles And Tendons
160 26478 Other Therapeutic Procedures On Muscles And Tendons
160 26479 Other Therapeutic Procedures On Muscles And Tendons
160 26480 Other Therapeutic Procedures On Muscles And Tendons
160 26483 Other Therapeutic Procedures On Muscles And Tendons
160 26485 Other Therapeutic Procedures On Muscles And Tendons
160 26489 Other Therapeutic Procedures On Muscles And Tendons
160 26490 Other Therapeutic Procedures On Muscles And Tendons
160 26492 Other Therapeutic Procedures On Muscles And Tendons
160 26494 Other Therapeutic Procedures On Muscles And Tendons
160 26496 Other Therapeutic Procedures On Muscles And Tendons
160 26497 Other Therapeutic Procedures On Muscles And Tendons
160 26498 Other Therapeutic Procedures On Muscles And Tendons
160 26499 Other Therapeutic Procedures On Muscles And Tendons
160 26500 Other Therapeutic Procedures On Muscles And Tendons
160 26502 Other Therapeutic Procedures On Muscles And Tendons
160 26508 Other Therapeutic Procedures On Muscles And Tendons
160 26510 Other Therapeutic Procedures On Muscles And Tendons
162 26516 Other Or Therapeutic Procedures On Joints
162 26517 Other Or Therapeutic Procedures On Joints
162 26518 Other Or Therapeutic Procedures On Joints
150 26520 Division Of Joint Capsule, Ligament Or Cartilage
150 26525 Division Of Joint Capsule, Ligament Or Cartilage
154 26530 Arthroplasty Other Than Hip Or Knee
154 26531 Arthroplasty Other Than Hip Or Knee
154 26535 Arthroplasty Other Than Hip Or Knee
154 26536 Arthroplasty Other Than Hip Or Knee
162 26540 Other Or Therapeutic Procedures On Joints
162 26541 Other Or Therapeutic Procedures On Joints
162 26542 Other Or Therapeutic Procedures On Joints
162 26545 Other Or Therapeutic Procedures On Joints
161 26546 Other Or Therapeutic Procedures On Bone
162 26548 Other Or Therapeutic Procedures On Joints
160 26550 Other Therapeutic Procedures On Muscles And Tendons
161 26551 Other Or Therapeutic Procedures On Bone
161 26553 Other Or Therapeutic Procedures On Bone
161 26554 Other Or Therapeutic Procedures On Bone
Blue Cross NC Proprietary and Confidential 18 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
161 26555 Other Or Therapeutic Procedures On Bone
162 26556 Other Or Therapeutic Procedures On Joints
175 26560 Other Or Therapeutic Procedures On Skin And Breast
175 26561 Other Or Therapeutic Procedures On Skin And Breast
175 26562 Other Or Therapeutic Procedures On Skin And Breast
161 26565 Other Or Therapeutic Procedures On Bone
161 26567 Other Or Therapeutic Procedures On Bone
161 26568 Other Or Therapeutic Procedures On Bone
160 26580 Other Therapeutic Procedures On Muscles And Tendons
164 26587 Other Or Therapeutic Procedures On Musculoskeletal System
164 26590 Other Or Therapeutic Procedures On Musculoskeletal System
160 26591 Other Therapeutic Procedures On Muscles And Tendons
160 26593 Other Therapeutic Procedures On Muscles And Tendons
175 26596 Other Or Therapeutic Procedures On Skin And Breast
148 26600 Other Fracture And Dislocation Procedure
148 26605 Other Fracture And Dislocation Procedure
148 26607 Other Fracture And Dislocation Procedure
148 26608 Other Fracture And Dislocation Procedure
148 26615 Other Fracture And Dislocation Procedure
148 26641 Other Fracture And Dislocation Procedure
148 26645 Other Fracture And Dislocation Procedure
148 26650 Other Fracture And Dislocation Procedure
148 26665 Other Fracture And Dislocation Procedure
148 26670 Other Fracture And Dislocation Procedure
148 26675 Other Fracture And Dislocation Procedure
148 26676 Other Fracture And Dislocation Procedure
148 26685 Other Fracture And Dislocation Procedure
148 26686 Other Fracture And Dislocation Procedure
148 26700 Other Fracture And Dislocation Procedure
148 26705 Other Fracture And Dislocation Procedure
148 26706 Other Fracture And Dislocation Procedure
148 26715 Other Fracture And Dislocation Procedure
148 26720 Other Fracture And Dislocation Procedure
148 26725 Other Fracture And Dislocation Procedure
148 26727 Other Fracture And Dislocation Procedure
148 26735 Other Fracture And Dislocation Procedure
148 26740 Other Fracture And Dislocation Procedure
148 26742 Other Fracture And Dislocation Procedure
148 26746 Other Fracture And Dislocation Procedure
148 26750 Other Fracture And Dislocation Procedure
148 26755 Other Fracture And Dislocation Procedure
148 26756 Other Fracture And Dislocation Procedure
148 26765 Other Fracture And Dislocation Procedure
148 26770 Other Fracture And Dislocation Procedure
148 26775 Other Fracture And Dislocation Procedure
148 26776 Other Fracture And Dislocation Procedure
148 26785 Other Fracture And Dislocation Procedure
162 26820 Other Or Therapeutic Procedures On Joints
162 26841 Other Or Therapeutic Procedures On Joints
162 26842 Other Or Therapeutic Procedures On Joints
162 26843 Other Or Therapeutic Procedures On Joints
162 26844 Other Or Therapeutic Procedures On Joints
162 26850 Other Or Therapeutic Procedures On Joints
162 26852 Other Or Therapeutic Procedures On Joints
162 26860 Other Or Therapeutic Procedures On Joints
162 26861 Other Or Therapeutic Procedures On Joints
162 26862 Other Or Therapeutic Procedures On Joints
162 26863 Other Or Therapeutic Procedures On Joints
164 26910 Other Or Therapeutic Procedures On Musculoskeletal System
164 26951 Other Or Therapeutic Procedures On Musculoskeletal System
164 26952 Other Or Therapeutic Procedures On Musculoskeletal System
164 26989 Other Or Therapeutic Procedures On Musculoskeletal System
162 26990 Other Or Therapeutic Procedures On Joints
162 26991 Other Or Therapeutic Procedures On Joints
161 26992 Other Or Therapeutic Procedures On Bone
160 27000 Other Therapeutic Procedures On Muscles And Tendons
160 27001 Other Therapeutic Procedures On Muscles And Tendons
9 27003 Other Or Therapeutic Nervous System Procedures
160 27005 Other Therapeutic Procedures On Muscles And Tendons
160 27006 Other Therapeutic Procedures On Muscles And Tendons
160 27025 Other Therapeutic Procedures On Muscles And Tendons
160 27027 Other Therapeutic Procedures On Muscles And Tendons
162 27030 Other Or Therapeutic Procedures On Joints
162 27033 Other Or Therapeutic Procedures On Joints
Blue Cross NC Proprietary and Confidential 19 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
9 27035 Other Or Therapeutic Nervous System Procedures
150 27036 Division Of Joint Capsule, Ligament Or Cartilage
159 27040 Other Diagnostic Procedures On Musculoskeletal System
159 27041 Other Diagnostic Procedures On Musculoskeletal System
170 27043 Excision Of Skin Lesion
160 27045 Other Therapeutic Procedures On Muscles And Tendons
170 27047 Excision Of Skin Lesion
160 27048 Other Therapeutic Procedures On Muscles And Tendons
160 27049 Other Therapeutic Procedures On Muscles And Tendons
159 27050 Other Diagnostic Procedures On Musculoskeletal System
159 27052 Other Diagnostic Procedures On Musculoskeletal System
162 27054 Other Or Therapeutic Procedures On Joints
160 27057 Other Therapeutic Procedures On Muscles And Tendons
160 27059 Other Therapeutic Procedures On Muscles And Tendons
160 27060 Other Therapeutic Procedures On Muscles And Tendons
160 27062 Other Therapeutic Procedures On Muscles And Tendons
142 27065 Partial Excision Bone
142 27066 Partial Excision Bone
142 27067 Partial Excision Bone
142 27070 Partial Excision Bone
142 27071 Partial Excision Bone
142 27075 Partial Excision Bone
142 27076 Partial Excision Bone
142 27077 Partial Excision Bone
142 27078 Partial Excision Bone
161 27080 Other Or Therapeutic Procedures On Bone
175 27086 Other Or Therapeutic Procedures On Skin And Breast
160 27087 Other Therapeutic Procedures On Muscles And Tendons
162 27090 Other Or Therapeutic Procedures On Joints
162 27091 Other Or Therapeutic Procedures On Joints
226 27093 Other Diagnostic Radiology And Related Techniques
226 27095 Other Diagnostic Radiology And Related Techniques
226 27096 Other Diagnostic Radiology And Related Techniques
160 27097 Other Therapeutic Procedures On Muscles And Tendons
160 27098 Other Therapeutic Procedures On Muscles And Tendons
160 27100 Other Therapeutic Procedures On Muscles And Tendons
160 27105 Other Therapeutic Procedures On Muscles And Tendons
160 27110 Other Therapeutic Procedures On Muscles And Tendons
160 27111 Other Therapeutic Procedures On Muscles And Tendons
162 27120 Other Or Therapeutic Procedures On Joints
142 27122 Partial Excision Bone
153 27125 Hip Replacement, Total And Partial
153 27130 Hip Replacement, Total And Partial
153 27132 Hip Replacement, Total And Partial
153 27134 Hip Replacement, Total And Partial
153 27137 Hip Replacement, Total And Partial
153 27138 Hip Replacement, Total And Partial
161 27140 Other Or Therapeutic Procedures On Bone
162 27146 Other Or Therapeutic Procedures On Joints
162 27147 Other Or Therapeutic Procedures On Joints
161 27151 Other Or Therapeutic Procedures On Bone
162 27156 Other Or Therapeutic Procedures On Joints
162 27158 Other Or Therapeutic Procedures On Joints
161 27161 Other Or Therapeutic Procedures On Bone
161 27165 Other Or Therapeutic Procedures On Bone
161 27170 Other Or Therapeutic Procedures On Bone
146 27175 Treatment, Fracture Or Dislocation Of Hip And Femur
146 27176 Treatment, Fracture Or Dislocation Of Hip And Femur
146 27177 Treatment, Fracture Or Dislocation Of Hip And Femur
146 27178 Treatment, Fracture Or Dislocation Of Hip And Femur
146 27179 Treatment, Fracture Or Dislocation Of Hip And Femur
146 27181 Treatment, Fracture Or Dislocation Of Hip And Femur
146 27185 Treatment, Fracture Or Dislocation Of Hip And Femur
146 27187 Treatment, Fracture Or Dislocation Of Hip And Femur
148 27197 Other Fracture And Dislocation Procedure
148 27198 Other Fracture And Dislocation Procedure
148 27200 Other Fracture And Dislocation Procedure
148 27202 Other Fracture And Dislocation Procedure
148 27215 Other Fracture And Dislocation Procedure
148 27216 Other Fracture And Dislocation Procedure
148 27217 Other Fracture And Dislocation Procedure
148 27218 Other Fracture And Dislocation Procedure
146 27220 Treatment, Fracture Or Dislocation Of Hip And Femur
146 27222 Treatment, Fracture Or Dislocation Of Hip And Femur
Blue Cross NC Proprietary and Confidential 20 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
148 27226 Other Fracture And Dislocation Procedure
148 27227 Other Fracture And Dislocation Procedure
148 27228 Other Fracture And Dislocation Procedure
146 27230 Treatment, Fracture Or Dislocation Of Hip And Femur
146 27232 Treatment, Fracture Or Dislocation Of Hip And Femur
146 27235 Treatment, Fracture Or Dislocation Of Hip And Femur
146 27236 Treatment, Fracture Or Dislocation Of Hip And Femur
146 27238 Treatment, Fracture Or Dislocation Of Hip And Femur
146 27240 Treatment, Fracture Or Dislocation Of Hip And Femur
146 27244 Treatment, Fracture Or Dislocation Of Hip And Femur
146 27245 Treatment, Fracture Or Dislocation Of Hip And Femur
146 27246 Treatment, Fracture Or Dislocation Of Hip And Femur
146 27248 Treatment, Fracture Or Dislocation Of Hip And Femur
146 27250 Treatment, Fracture Or Dislocation Of Hip And Femur
146 27252 Treatment, Fracture Or Dislocation Of Hip And Femur
146 27253 Treatment, Fracture Or Dislocation Of Hip And Femur
146 27254 Treatment, Fracture Or Dislocation Of Hip And Femur
146 27256 Treatment, Fracture Or Dislocation Of Hip And Femur
146 27257 Treatment, Fracture Or Dislocation Of Hip And Femur
146 27258 Treatment, Fracture Or Dislocation Of Hip And Femur
146 27259 Treatment, Fracture Or Dislocation Of Hip And Femur
146 27265 Treatment, Fracture Or Dislocation Of Hip And Femur
146 27266 Treatment, Fracture Or Dislocation Of Hip And Femur
146 27267 Treatment, Fracture Or Dislocation Of Hip And Femur
146 27268 Treatment, Fracture Or Dislocation Of Hip And Femur
146 27269 Treatment, Fracture Or Dislocation Of Hip And Femur
162 27275 Other Or Therapeutic Procedures On Joints
162 27279 Other Or Therapeutic Procedures On Joints
162 27280 Other Or Therapeutic Procedures On Joints
162 27282 Other Or Therapeutic Procedures On Joints
162 27284 Other Or Therapeutic Procedures On Joints
162 27286 Other Or Therapeutic Procedures On Joints
157 27290 Amputation Of Lower Extremity
157 27295 Amputation Of Lower Extremity
162 27299 Other Or Therapeutic Procedures On Joints
160 27301 Other Therapeutic Procedures On Muscles And Tendons
161 27303 Other Or Therapeutic Procedures On Bone
160 27305 Other Therapeutic Procedures On Muscles And Tendons
160 27306 Other Therapeutic Procedures On Muscles And Tendons
160 27307 Other Therapeutic Procedures On Muscles And Tendons
162 27310 Other Or Therapeutic Procedures On Joints
159 27323 Other Diagnostic Procedures On Musculoskeletal System
159 27324 Other Diagnostic Procedures On Musculoskeletal System
9 27325 Other Or Therapeutic Nervous System Procedures
9 27326 Other Or Therapeutic Nervous System Procedures
170 27327 Excision Of Skin Lesion
160 27328 Other Therapeutic Procedures On Muscles And Tendons
160 27329 Other Therapeutic Procedures On Muscles And Tendons
159 27330 Other Diagnostic Procedures On Musculoskeletal System
160 27331 Other Therapeutic Procedures On Muscles And Tendons
151 27332 Excision Of Semilunar Cartilage Of Knee
151 27333 Excision Of Semilunar Cartilage Of Knee
162 27334 Other Or Therapeutic Procedures On Joints
162 27335 Other Or Therapeutic Procedures On Joints
170 27337 Excision Of Skin Lesion
160 27339 Other Therapeutic Procedures On Muscles And Tendons
160 27340 Other Therapeutic Procedures On Muscles And Tendons
160 27345 Other Therapeutic Procedures On Muscles And Tendons
151 27347 Excision Of Semilunar Cartilage Of Knee
142 27350 Partial Excision Bone
142 27355 Partial Excision Bone
142 27356 Partial Excision Bone
142 27357 Partial Excision Bone
142 27358 Partial Excision Bone
142 27360 Partial Excision Bone
160 27364 Other Therapeutic Procedures On Muscles And Tendons
142 27365 Partial Excision Bone
156 27369 Injections And Aspirations Of Muscles, Tendons, Bursa, Joints And Soft Tissue
160 27372 Other Therapeutic Procedures On Muscles And Tendons
160 27380 Other Therapeutic Procedures On Muscles And Tendons
160 27381 Other Therapeutic Procedures On Muscles And Tendons
160 27385 Other Therapeutic Procedures On Muscles And Tendons
160 27386 Other Therapeutic Procedures On Muscles And Tendons
160 27390 Other Therapeutic Procedures On Muscles And Tendons
Blue Cross NC Proprietary and Confidential 21 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
160 27391 Other Therapeutic Procedures On Muscles And Tendons
160 27392 Other Therapeutic Procedures On Muscles And Tendons
160 27393 Other Therapeutic Procedures On Muscles And Tendons
160 27394 Other Therapeutic Procedures On Muscles And Tendons
160 27395 Other Therapeutic Procedures On Muscles And Tendons
160 27396 Other Therapeutic Procedures On Muscles And Tendons
160 27397 Other Therapeutic Procedures On Muscles And Tendons
160 27400 Other Therapeutic Procedures On Muscles And Tendons
151 27403 Excision Of Semilunar Cartilage Of Knee
151 27405 Excision Of Semilunar Cartilage Of Knee
151 27407 Excision Of Semilunar Cartilage Of Knee
151 27409 Excision Of Semilunar Cartilage Of Knee
162 27412 Other Or Therapeutic Procedures On Joints
162 27415 Other Or Therapeutic Procedures On Joints
162 27416 Other Or Therapeutic Procedures On Joints
142 27418 Partial Excision Bone
152 27420 Arthroplasty Knee
152 27422 Arthroplasty Knee
152 27424 Arthroplasty Knee
150 27425 Division Of Joint Capsule, Ligament Or Cartilage
152 27427 Arthroplasty Knee
152 27428 Arthroplasty Knee
152 27429 Arthroplasty Knee
160 27430 Other Therapeutic Procedures On Muscles And Tendons
150 27435 Division Of Joint Capsule, Ligament Or Cartilage
152 27437 Arthroplasty Knee
152 27438 Arthroplasty Knee
152 27440 Arthroplasty Knee
152 27441 Arthroplasty Knee
152 27442 Arthroplasty Knee
152 27443 Arthroplasty Knee
152 27445 Arthroplasty Knee
152 27446 Arthroplasty Knee
152 27447 Arthroplasty Knee
161 27448 Other Or Therapeutic Procedures On Bone
161 27450 Other Or Therapeutic Procedures On Bone
161 27454 Other Or Therapeutic Procedures On Bone
161 27455 Other Or Therapeutic Procedures On Bone
161 27457 Other Or Therapeutic Procedures On Bone
161 27465 Other Or Therapeutic Procedures On Bone
161 27466 Other Or Therapeutic Procedures On Bone
161 27468 Other Or Therapeutic Procedures On Bone
164 27470 Other Or Therapeutic Procedures On Musculoskeletal System
146 27472 Treatment, Fracture Or Dislocation Of Hip And Femur
161 27475 Other Or Therapeutic Procedures On Bone
161 27477 Other Or Therapeutic Procedures On Bone
161 27479 Other Or Therapeutic Procedures On Bone
161 27485 Other Or Therapeutic Procedures On Bone
152 27486 Arthroplasty Knee
152 27487 Arthroplasty Knee
162 27488 Other Or Therapeutic Procedures On Joints
146 27495 Treatment, Fracture Or Dislocation Of Hip And Femur
160 27496 Other Therapeutic Procedures On Muscles And Tendons
160 27497 Other Therapeutic Procedures On Muscles And Tendons
160 27498 Other Therapeutic Procedures On Muscles And Tendons
160 27499 Other Therapeutic Procedures On Muscles And Tendons
146 27500 Treatment, Fracture Or Dislocation Of Hip And Femur
146 27501 Treatment, Fracture Or Dislocation Of Hip And Femur
146 27502 Treatment, Fracture Or Dislocation Of Hip And Femur
146 27503 Treatment, Fracture Or Dislocation Of Hip And Femur
146 27506 Treatment, Fracture Or Dislocation Of Hip And Femur
146 27507 Treatment, Fracture Or Dislocation Of Hip And Femur
146 27508 Treatment, Fracture Or Dislocation Of Hip And Femur
146 27509 Treatment, Fracture Or Dislocation Of Hip And Femur
146 27510 Treatment, Fracture Or Dislocation Of Hip And Femur
146 27511 Treatment, Fracture Or Dislocation Of Hip And Femur
146 27513 Treatment, Fracture Or Dislocation Of Hip And Femur
146 27514 Treatment, Fracture Or Dislocation Of Hip And Femur
146 27516 Treatment, Fracture Or Dislocation Of Hip And Femur
146 27517 Treatment, Fracture Or Dislocation Of Hip And Femur
146 27519 Treatment, Fracture Or Dislocation Of Hip And Femur
147 27520 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 27524 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 27530 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
Blue Cross NC Proprietary and Confidential 22 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
147 27532 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 27535 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 27536 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 27538 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 27540 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 27550 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 27552 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 27556 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 27557 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 27558 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 27560 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 27562 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 27566 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
162 27570 Other Or Therapeutic Procedures On Joints
162 27580 Other Or Therapeutic Procedures On Joints
157 27590 Amputation Of Lower Extremity
157 27591 Amputation Of Lower Extremity
157 27592 Amputation Of Lower Extremity
157 27594 Amputation Of Lower Extremity
157 27596 Amputation Of Lower Extremity
157 27598 Amputation Of Lower Extremity
164 27599 Other Or Therapeutic Procedures On Musculoskeletal System
160 27600 Other Therapeutic Procedures On Muscles And Tendons
160 27601 Other Therapeutic Procedures On Muscles And Tendons
160 27602 Other Therapeutic Procedures On Muscles And Tendons
160 27603 Other Therapeutic Procedures On Muscles And Tendons
160 27604 Other Therapeutic Procedures On Muscles And Tendons
160 27605 Other Therapeutic Procedures On Muscles And Tendons
160 27606 Other Therapeutic Procedures On Muscles And Tendons
161 27607 Other Or Therapeutic Procedures On Bone
162 27610 Other Or Therapeutic Procedures On Joints
150 27612 Division Of Joint Capsule, Ligament Or Cartilage
159 27613 Other Diagnostic Procedures On Musculoskeletal System
159 27614 Other Diagnostic Procedures On Musculoskeletal System
160 27615 Other Therapeutic Procedures On Muscles And Tendons
160 27616 Other Therapeutic Procedures On Muscles And Tendons
170 27618 Excision Of Skin Lesion
160 27619 Other Therapeutic Procedures On Muscles And Tendons
159 27620 Other Diagnostic Procedures On Musculoskeletal System
162 27625 Other Or Therapeutic Procedures On Joints
160 27626 Other Therapeutic Procedures On Muscles And Tendons
160 27630 Other Therapeutic Procedures On Muscles And Tendons
170 27632 Excision Of Skin Lesion
160 27634 Other Therapeutic Procedures On Muscles And Tendons
142 27635 Partial Excision Bone
142 27637 Partial Excision Bone
142 27638 Partial Excision Bone
142 27640 Partial Excision Bone
142 27641 Partial Excision Bone
142 27645 Partial Excision Bone
142 27646 Partial Excision Bone
142 27647 Partial Excision Bone
226 27648 Other Diagnostic Radiology And Related Techniques
160 27650 Other Therapeutic Procedures On Muscles And Tendons
160 27652 Other Therapeutic Procedures On Muscles And Tendons
160 27654 Other Therapeutic Procedures On Muscles And Tendons
160 27656 Other Therapeutic Procedures On Muscles And Tendons
160 27658 Other Therapeutic Procedures On Muscles And Tendons
160 27659 Other Therapeutic Procedures On Muscles And Tendons
160 27664 Other Therapeutic Procedures On Muscles And Tendons
160 27665 Other Therapeutic Procedures On Muscles And Tendons
160 27675 Other Therapeutic Procedures On Muscles And Tendons
160 27676 Other Therapeutic Procedures On Muscles And Tendons
160 27680 Other Therapeutic Procedures On Muscles And Tendons
160 27681 Other Therapeutic Procedures On Muscles And Tendons
160 27685 Other Therapeutic Procedures On Muscles And Tendons
160 27686 Other Therapeutic Procedures On Muscles And Tendons
160 27687 Other Therapeutic Procedures On Muscles And Tendons
160 27690 Other Therapeutic Procedures On Muscles And Tendons
160 27691 Other Therapeutic Procedures On Muscles And Tendons
160 27692 Other Therapeutic Procedures On Muscles And Tendons
162 27695 Other Or Therapeutic Procedures On Joints
162 27696 Other Or Therapeutic Procedures On Joints
162 27698 Other Or Therapeutic Procedures On Joints
Blue Cross NC Proprietary and Confidential 23 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
154 27700 Arthroplasty Other Than Hip Or Knee
154 27702 Arthroplasty Other Than Hip Or Knee
154 27703 Arthroplasty Other Than Hip Or Knee
162 27704 Other Or Therapeutic Procedures On Joints
161 27705 Other Or Therapeutic Procedures On Bone
161 27707 Other Or Therapeutic Procedures On Bone
161 27709 Other Or Therapeutic Procedures On Bone
161 27712 Other Or Therapeutic Procedures On Bone
161 27715 Other Or Therapeutic Procedures On Bone
147 27720 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 27722 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 27724 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 27725 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 27726 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
161 27727 Other Or Therapeutic Procedures On Bone
161 27730 Other Or Therapeutic Procedures On Bone
161 27732 Other Or Therapeutic Procedures On Bone
161 27734 Other Or Therapeutic Procedures On Bone
161 27740 Other Or Therapeutic Procedures On Bone
161 27742 Other Or Therapeutic Procedures On Bone
161 27745 Other Or Therapeutic Procedures On Bone
147 27750 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 27752 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 27756 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 27758 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 27759 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 27760 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 27762 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 27766 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 27767 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 27768 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 27769 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 27780 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 27781 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 27784 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 27786 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 27788 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 27792 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 27808 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 27810 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 27814 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 27816 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 27818 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 27822 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 27823 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 27824 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 27825 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 27826 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 27827 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 27828 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 27829 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 27830 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 27831 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 27832 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 27840 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 27842 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 27846 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 27848 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
148 27860 Other Fracture And Dislocation Procedure
162 27870 Other Or Therapeutic Procedures On Joints
162 27871 Other Or Therapeutic Procedures On Joints
157 27880 Amputation Of Lower Extremity
157 27881 Amputation Of Lower Extremity
157 27882 Amputation Of Lower Extremity
157 27884 Amputation Of Lower Extremity
157 27886 Amputation Of Lower Extremity
157 27888 Amputation Of Lower Extremity
157 27889 Amputation Of Lower Extremity
160 27892 Other Therapeutic Procedures On Muscles And Tendons
160 27893 Other Therapeutic Procedures On Muscles And Tendons
160 27894 Other Therapeutic Procedures On Muscles And Tendons
164 27899 Other Or Therapeutic Procedures On Musculoskeletal System
160 28001 Other Therapeutic Procedures On Muscles And Tendons
160 28002 Other Therapeutic Procedures On Muscles And Tendons
Blue Cross NC Proprietary and Confidential 24 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
160 28003 Other Therapeutic Procedures On Muscles And Tendons
161 28005 Other Or Therapeutic Procedures On Bone
160 28008 Other Therapeutic Procedures On Muscles And Tendons
160 28010 Other Therapeutic Procedures On Muscles And Tendons
160 28011 Other Therapeutic Procedures On Muscles And Tendons
162 28020 Other Or Therapeutic Procedures On Joints
162 28022 Other Or Therapeutic Procedures On Joints
162 28024 Other Or Therapeutic Procedures On Joints
6 28035 Decompression Peripheral Nerve
170 28039 Excision Of Skin Lesion
160 28041 Other Therapeutic Procedures On Muscles And Tendons
170 28043 Excision Of Skin Lesion
160 28045 Other Therapeutic Procedures On Muscles And Tendons
160 28046 Other Therapeutic Procedures On Muscles And Tendons
160 28047 Other Therapeutic Procedures On Muscles And Tendons
159 28050 Other Diagnostic Procedures On Musculoskeletal System
159 28052 Other Diagnostic Procedures On Musculoskeletal System
159 28054 Other Diagnostic Procedures On Musculoskeletal System
9 28055 Other Or Therapeutic Nervous System Procedures
160 28060 Other Therapeutic Procedures On Muscles And Tendons
160 28062 Other Therapeutic Procedures On Muscles And Tendons
162 28070 Other Or Therapeutic Procedures On Joints
162 28072 Other Or Therapeutic Procedures On Joints
9 28080 Other Or Therapeutic Nervous System Procedures
160 28086 Other Therapeutic Procedures On Muscles And Tendons
160 28088 Other Therapeutic Procedures On Muscles And Tendons
160 28090 Other Therapeutic Procedures On Muscles And Tendons
160 28092 Other Therapeutic Procedures On Muscles And Tendons
142 28100 Partial Excision Bone
161 28102 Other Or Therapeutic Procedures On Bone
161 28103 Other Or Therapeutic Procedures On Bone
142 28104 Partial Excision Bone
161 28106 Other Or Therapeutic Procedures On Bone
161 28107 Other Or Therapeutic Procedures On Bone
142 28108 Partial Excision Bone
142 28110 Partial Excision Bone
142 28111 Partial Excision Bone
142 28112 Partial Excision Bone
142 28113 Partial Excision Bone
142 28114 Partial Excision Bone
161 28116 Other Or Therapeutic Procedures On Bone
142 28118 Partial Excision Bone
142 28119 Partial Excision Bone
142 28120 Partial Excision Bone
142 28122 Partial Excision Bone
142 28124 Partial Excision Bone
142 28126 Partial Excision Bone
142 28130 Partial Excision Bone
142 28140 Partial Excision Bone
142 28150 Partial Excision Bone
142 28153 Partial Excision Bone
142 28160 Partial Excision Bone
142 28171 Partial Excision Bone
142 28173 Partial Excision Bone
142 28175 Partial Excision Bone
175 28190 Other Or Therapeutic Procedures On Skin And Breast
160 28192 Other Therapeutic Procedures On Muscles And Tendons
160 28193 Other Therapeutic Procedures On Muscles And Tendons
160 28200 Other Therapeutic Procedures On Muscles And Tendons
160 28202 Other Therapeutic Procedures On Muscles And Tendons
160 28208 Other Therapeutic Procedures On Muscles And Tendons
160 28210 Other Therapeutic Procedures On Muscles And Tendons
160 28220 Other Therapeutic Procedures On Muscles And Tendons
160 28222 Other Therapeutic Procedures On Muscles And Tendons
160 28225 Other Therapeutic Procedures On Muscles And Tendons
160 28226 Other Therapeutic Procedures On Muscles And Tendons
160 28230 Other Therapeutic Procedures On Muscles And Tendons
160 28232 Other Therapeutic Procedures On Muscles And Tendons
160 28234 Other Therapeutic Procedures On Muscles And Tendons
160 28238 Other Therapeutic Procedures On Muscles And Tendons
160 28240 Other Therapeutic Procedures On Muscles And Tendons
160 28250 Other Therapeutic Procedures On Muscles And Tendons
150 28260 Division Of Joint Capsule, Ligament Or Cartilage
150 28261 Division Of Joint Capsule, Ligament Or Cartilage
Blue Cross NC Proprietary and Confidential 25 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
150 28262 Division Of Joint Capsule, Ligament Or Cartilage
150 28264 Division Of Joint Capsule, Ligament Or Cartilage
150 28270 Division Of Joint Capsule, Ligament Or Cartilage
150 28272 Division Of Joint Capsule, Ligament Or Cartilage
175 28280 Other Or Therapeutic Procedures On Skin And Breast
143 28285 Bunionectomy Or Repair Of Toe Deformities
143 28286 Bunionectomy Or Repair Of Toe Deformities
142 28288 Partial Excision Bone
143 28289 Bunionectomy Or Repair Of Toe Deformities
143 28291 Bunionectomy Or Repair Of Toe Deformities
143 28292 Bunionectomy Or Repair Of Toe Deformities
143 28295 Bunionectomy Or Repair Of Toe Deformities
143 28296 Bunionectomy Or Repair Of Toe Deformities
143 28297 Bunionectomy Or Repair Of Toe Deformities
143 28298 Bunionectomy Or Repair Of Toe Deformities
143 28299 Bunionectomy Or Repair Of Toe Deformities
161 28300 Other Or Therapeutic Procedures On Bone
161 28302 Other Or Therapeutic Procedures On Bone
161 28304 Other Or Therapeutic Procedures On Bone
161 28305 Other Or Therapeutic Procedures On Bone
161 28306 Other Or Therapeutic Procedures On Bone
161 28307 Other Or Therapeutic Procedures On Bone
161 28308 Other Or Therapeutic Procedures On Bone
161 28309 Other Or Therapeutic Procedures On Bone
161 28310 Other Or Therapeutic Procedures On Bone
161 28312 Other Or Therapeutic Procedures On Bone
143 28313 Bunionectomy Or Repair Of Toe Deformities
161 28315 Other Or Therapeutic Procedures On Bone
147 28320 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 28322 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
143 28340 Bunionectomy Or Repair Of Toe Deformities
143 28341 Bunionectomy Or Repair Of Toe Deformities
161 28344 Other Or Therapeutic Procedures On Bone
143 28345 Bunionectomy Or Repair Of Toe Deformities
160 28360 Other Therapeutic Procedures On Muscles And Tendons
147 28400 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 28405 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 28406 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 28415 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 28420 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 28430 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 28435 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 28436 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 28445 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 28446 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 28450 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 28455 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 28456 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 28465 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 28470 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 28475 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 28476 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 28485 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 28490 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 28495 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 28496 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 28505 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 28510 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 28515 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 28525 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 28530 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 28531 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 28540 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 28545 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 28546 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 28555 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 28570 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 28575 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 28576 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 28585 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 28600 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 28605 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 28606 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 28615 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
Blue Cross NC Proprietary and Confidential 26 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
147 28630 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 28635 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 28636 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 28645 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 28660 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 28665 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 28666 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 28675 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
162 28705 Other Or Therapeutic Procedures On Joints
162 28715 Other Or Therapeutic Procedures On Joints
162 28725 Other Or Therapeutic Procedures On Joints
162 28730 Other Or Therapeutic Procedures On Joints
162 28735 Other Or Therapeutic Procedures On Joints
160 28737 Other Therapeutic Procedures On Muscles And Tendons
162 28740 Other Or Therapeutic Procedures On Joints
162 28750 Other Or Therapeutic Procedures On Joints
143 28755 Bunionectomy Or Repair Of Toe Deformities
143 28760 Bunionectomy Or Repair Of Toe Deformities
157 28800 Amputation Of Lower Extremity
157 28805 Amputation Of Lower Extremity
157 28810 Amputation Of Lower Extremity
157 28820 Amputation Of Lower Extremity
157 28825 Amputation Of Lower Extremity
160 28890 Other Therapeutic Procedures On Muscles And Tendons
164 28899 Other Or Therapeutic Procedures On Musculoskeletal System
214 29000 Traction, Splints, And Other Wound Care
214 29010 Traction, Splints, And Other Wound Care
214 29015 Traction, Splints, And Other Wound Care
214 29035 Traction, Splints, And Other Wound Care
214 29040 Traction, Splints, And Other Wound Care
214 29044 Traction, Splints, And Other Wound Care
214 29046 Traction, Splints, And Other Wound Care
214 29049 Traction, Splints, And Other Wound Care
214 29055 Traction, Splints, And Other Wound Care
214 29058 Traction, Splints, And Other Wound Care
214 29065 Traction, Splints, And Other Wound Care
214 29075 Traction, Splints, And Other Wound Care
214 29085 Traction, Splints, And Other Wound Care
214 29086 Traction, Splints, And Other Wound Care
214 29105 Traction, Splints, And Other Wound Care
214 29125 Traction, Splints, And Other Wound Care
214 29126 Traction, Splints, And Other Wound Care
214 29130 Traction, Splints, And Other Wound Care
214 29131 Traction, Splints, And Other Wound Care
214 29200 Traction, Splints, And Other Wound Care
214 29240 Traction, Splints, And Other Wound Care
214 29260 Traction, Splints, And Other Wound Care
214 29280 Traction, Splints, And Other Wound Care
214 29305 Traction, Splints, And Other Wound Care
214 29325 Traction, Splints, And Other Wound Care
214 29345 Traction, Splints, And Other Wound Care
214 29355 Traction, Splints, And Other Wound Care
214 29358 Traction, Splints, And Other Wound Care
214 29365 Traction, Splints, And Other Wound Care
214 29405 Traction, Splints, And Other Wound Care
214 29425 Traction, Splints, And Other Wound Care
214 29435 Traction, Splints, And Other Wound Care
214 29440 Traction, Splints, And Other Wound Care
214 29445 Traction, Splints, And Other Wound Care
214 29450 Traction, Splints, And Other Wound Care
214 29505 Traction, Splints, And Other Wound Care
214 29515 Traction, Splints, And Other Wound Care
214 29520 Traction, Splints, And Other Wound Care
214 29530 Traction, Splints, And Other Wound Care
214 29540 Traction, Splints, And Other Wound Care
214 29550 Traction, Splints, And Other Wound Care
214 29580 Traction, Splints, And Other Wound Care
214 29581 Traction, Splints, And Other Wound Care
214 29584 Traction, Splints, And Other Wound Care
163 29700 Other Non-Or Therapeutic Procedures On Musculoskeletal System
163 29705 Other Non-Or Therapeutic Procedures On Musculoskeletal System
163 29710 Other Non-Or Therapeutic Procedures On Musculoskeletal System
214 29720 Traction, Splints, And Other Wound Care
214 29730 Traction, Splints, And Other Wound Care
Blue Cross NC Proprietary and Confidential 27 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
214 29740 Traction, Splints, And Other Wound Care
214 29750 Traction, Splints, And Other Wound Care
214 29799 Traction, Splints, And Other Wound Care
149 29800 Arthroscopy
149 29804 Arthroscopy
149 29805 Arthroscopy
162 29806 Other Or Therapeutic Procedures On Joints
162 29807 Other Or Therapeutic Procedures On Joints
149 29819 Arthroscopy
162 29820 Other Or Therapeutic Procedures On Joints
162 29821 Other Or Therapeutic Procedures On Joints
162 29822 Other Or Therapeutic Procedures On Joints
162 29823 Other Or Therapeutic Procedures On Joints
142 29824 Partial Excision Bone
150 29825 Division Of Joint Capsule, Ligament Or Cartilage
154 29826 Arthroplasty Other Than Hip Or Knee
160 29827 Other Therapeutic Procedures On Muscles And Tendons
160 29828 Other Therapeutic Procedures On Muscles And Tendons
149 29830 Arthroscopy
149 29834 Arthroscopy
162 29835 Other Or Therapeutic Procedures On Joints
162 29836 Other Or Therapeutic Procedures On Joints
162 29837 Other Or Therapeutic Procedures On Joints
162 29838 Other Or Therapeutic Procedures On Joints
149 29840 Arthroscopy
149 29843 Arthroscopy
162 29844 Other Or Therapeutic Procedures On Joints
162 29845 Other Or Therapeutic Procedures On Joints
162 29846 Other Or Therapeutic Procedures On Joints
145 29847 Treatment, Fracture Or Dislocation Of Radius And Ulna
6 29848 Decompression Peripheral Nerve
147 29850 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 29851 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 29855 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
147 29856 Treatment, Fracture Or Dislocation Of Lower Extremity (Other Than Hip Or Femur)
149 29860 Arthroscopy
162 29861 Other Or Therapeutic Procedures On Joints
162 29862 Other Or Therapeutic Procedures On Joints
162 29863 Other Or Therapeutic Procedures On Joints
162 29866 Other Or Therapeutic Procedures On Joints
162 29867 Other Or Therapeutic Procedures On Joints
162 29868 Other Or Therapeutic Procedures On Joints
149 29870 Arthroscopy
149 29871 Arthroscopy
150 29873 Division Of Joint Capsule, Ligament Or Cartilage
162 29874 Other Or Therapeutic Procedures On Joints
162 29875 Other Or Therapeutic Procedures On Joints
162 29876 Other Or Therapeutic Procedures On Joints
162 29877 Other Or Therapeutic Procedures On Joints
162 29879 Other Or Therapeutic Procedures On Joints
151 29880 Excision Of Semilunar Cartilage Of Knee
151 29881 Excision Of Semilunar Cartilage Of Knee
151 29882 Excision Of Semilunar Cartilage Of Knee
151 29883 Excision Of Semilunar Cartilage Of Knee
150 29884 Division Of Joint Capsule, Ligament Or Cartilage
162 29885 Other Or Therapeutic Procedures On Joints
162 29886 Other Or Therapeutic Procedures On Joints
162 29887 Other Or Therapeutic Procedures On Joints
149 29888 Arthroscopy
149 29889 Arthroscopy
162 29891 Other Or Therapeutic Procedures On Joints
162 29892 Other Or Therapeutic Procedures On Joints
170 29893 Excision Of Skin Lesion
162 29894 Other Or Therapeutic Procedures On Joints
162 29895 Other Or Therapeutic Procedures On Joints
162 29897 Other Or Therapeutic Procedures On Joints
162 29898 Other Or Therapeutic Procedures On Joints
162 29899 Other Or Therapeutic Procedures On Joints
149 29900 Arthroscopy
162 29901 Other Or Therapeutic Procedures On Joints
162 29902 Other Or Therapeutic Procedures On Joints
162 29904 Other Or Therapeutic Procedures On Joints
162 29905 Other Or Therapeutic Procedures On Joints
162 29906 Other Or Therapeutic Procedures On Joints
Blue Cross NC Proprietary and Confidential 28 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
162 29907 Other Or Therapeutic Procedures On Joints
153 29914 Hip Replacement, Total And Partial
153 29915 Hip Replacement, Total And Partial
153 29916 Hip Replacement, Total And Partial
149 29999 Arthroscopy
33 30000 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
32 30020 Other Non-Or Therapeutic Procedures On Nose, Mouth And Pharynx
31 30100 Diagnostic Procedures On Nose, Mouth And Pharynx
33 30110 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 30115 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 30117 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
32 30118 Other Non-Or Therapeutic Procedures On Nose, Mouth And Pharynx
175 30120 Other Or Therapeutic Procedures On Skin And Breast
175 30124 Other Or Therapeutic Procedures On Skin And Breast
32 30125 Other Non-Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 30130 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 30140 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 30150 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 30160 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
32 30200 Other Non-Or Therapeutic Procedures On Nose, Mouth And Pharynx
32 30210 Other Non-Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 30220 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
229 30300 Nonoperative Removal Of Foreign Body
33 30310 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
229 30320 Nonoperative Removal Of Foreign Body
28 30400 Plastic Procedures On Nose
28 30410 Plastic Procedures On Nose
28 30420 Plastic Procedures On Nose
28 30430 Plastic Procedures On Nose
28 30435 Plastic Procedures On Nose
28 30450 Plastic Procedures On Nose
28 30460 Plastic Procedures On Nose
28 30462 Plastic Procedures On Nose
28 30465 Plastic Procedures On Nose
28 30520 Plastic Procedures On Nose
28 30540 Plastic Procedures On Nose
28 30545 Plastic Procedures On Nose
33 30560 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 30580 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 30600 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
28 30620 Plastic Procedures On Nose
28 30630 Plastic Procedures On Nose
33 30801 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 30802 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
27 30901 Control Of Epistaxis
27 30903 Control Of Epistaxis
27 30905 Control Of Epistaxis
27 30906 Control Of Epistaxis
27 30915 Control Of Epistaxis
27 30920 Control Of Epistaxis
144 30930 Treatment, Facial Fracture Or Dislocation
33 30999 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
32 31000 Other Non-Or Therapeutic Procedures On Nose, Mouth And Pharynx
32 31002 Other Non-Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 31020 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 31030 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 31032 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 31040 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 31050 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 31051 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 31070 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 31075 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 31080 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 31081 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 31084 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 31085 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 31086 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 31087 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 31090 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 31200 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 31201 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 31205 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
142 31225 Partial Excision Bone
142 31230 Partial Excision Bone
Blue Cross NC Proprietary and Confidential 29 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
31 31231 Diagnostic Procedures On Nose, Mouth And Pharynx
31 31233 Diagnostic Procedures On Nose, Mouth And Pharynx
31 31235 Diagnostic Procedures On Nose, Mouth And Pharynx
31 31237 Diagnostic Procedures On Nose, Mouth And Pharynx
27 31238 Control Of Epistaxis
33 31239 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 31240 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
27 31241 Control Of Epistaxis
33 31253 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 31254 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 31255 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 31256 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 31257 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 31259 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 31267 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 31276 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 31287 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 31288 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 31290 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 31291 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 31292 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 31293 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 31294 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 31295 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 31296 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 31297 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 31298 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 31299 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
42 31300 Other Or Therapeutic Procedures On Respiratory System
42 31360 Other Or Therapeutic Procedures On Respiratory System
42 31365 Other Or Therapeutic Procedures On Respiratory System
42 31367 Other Or Therapeutic Procedures On Respiratory System
42 31368 Other Or Therapeutic Procedures On Respiratory System
42 31370 Other Or Therapeutic Procedures On Respiratory System
42 31375 Other Or Therapeutic Procedures On Respiratory System
42 31380 Other Or Therapeutic Procedures On Respiratory System
42 31382 Other Or Therapeutic Procedures On Respiratory System
33 31390 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 31395 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
42 31400 Other Or Therapeutic Procedures On Respiratory System
42 31420 Other Or Therapeutic Procedures On Respiratory System
216 31500 Respiratory Intubation And Mechanical Ventilation
41 31502 Other Non-Or Therapeutic Procedures On Respiratory System
35 31505 Tracheoscopy And Laryngoscopy With Biopsy
35 31510 Tracheoscopy And Laryngoscopy With Biopsy
229 31511 Nonoperative Removal Of Foreign Body
41 31512 Other Non-Or Therapeutic Procedures On Respiratory System
41 31513 Other Non-Or Therapeutic Procedures On Respiratory System
35 31515 Tracheoscopy And Laryngoscopy With Biopsy
35 31520 Tracheoscopy And Laryngoscopy With Biopsy
35 31525 Tracheoscopy And Laryngoscopy With Biopsy
35 31526 Tracheoscopy And Laryngoscopy With Biopsy
42 31527 Other Or Therapeutic Procedures On Respiratory System
42 31528 Other Or Therapeutic Procedures On Respiratory System
42 31529 Other Or Therapeutic Procedures On Respiratory System
42 31530 Other Or Therapeutic Procedures On Respiratory System
42 31531 Other Or Therapeutic Procedures On Respiratory System
35 31535 Tracheoscopy And Laryngoscopy With Biopsy
35 31536 Tracheoscopy And Laryngoscopy With Biopsy
42 31540 Other Or Therapeutic Procedures On Respiratory System
42 31541 Other Or Therapeutic Procedures On Respiratory System
42 31545 Other Or Therapeutic Procedures On Respiratory System
42 31546 Other Or Therapeutic Procedures On Respiratory System
42 31551 Other Or Therapeutic Procedures On Respiratory System
42 31552 Other Or Therapeutic Procedures On Respiratory System
42 31553 Other Or Therapeutic Procedures On Respiratory System
42 31554 Other Or Therapeutic Procedures On Respiratory System
42 31560 Other Or Therapeutic Procedures On Respiratory System
42 31561 Other Or Therapeutic Procedures On Respiratory System
42 31570 Other Or Therapeutic Procedures On Respiratory System
42 31571 Other Or Therapeutic Procedures On Respiratory System
41 31572 Other Non-Or Therapeutic Procedures On Respiratory System
41 31573 Other Non-Or Therapeutic Procedures On Respiratory System
41 31574 Other Non-Or Therapeutic Procedures On Respiratory System
Blue Cross NC Proprietary and Confidential 30 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
35 31575 Tracheoscopy And Laryngoscopy With Biopsy
35 31576 Tracheoscopy And Laryngoscopy With Biopsy
229 31577 Nonoperative Removal Of Foreign Body
41 31578 Other Non-Or Therapeutic Procedures On Respiratory System
35 31579 Tracheoscopy And Laryngoscopy With Biopsy
42 31580 Other Or Therapeutic Procedures On Respiratory System
42 31584 Other Or Therapeutic Procedures On Respiratory System
42 31587 Other Or Therapeutic Procedures On Respiratory System
42 31590 Other Or Therapeutic Procedures On Respiratory System
42 31591 Other Or Therapeutic Procedures On Respiratory System
42 31592 Other Or Therapeutic Procedures On Respiratory System
42 31599 Other Or Therapeutic Procedures On Respiratory System
34 31600 Tracheostomy, Temporary And Permanent
34 31601 Tracheostomy, Temporary And Permanent
34 31603 Tracheostomy, Temporary And Permanent
34 31605 Tracheostomy, Temporary And Permanent
34 31610 Tracheostomy, Temporary And Permanent
42 31611 Other Or Therapeutic Procedures On Respiratory System
42 31612 Other Or Therapeutic Procedures On Respiratory System
34 31613 Tracheostomy, Temporary And Permanent
34 31614 Tracheostomy, Temporary And Permanent
35 31615 Tracheoscopy And Laryngoscopy With Biopsy
37 31622 Diagnostic Bronchoscopy And Biopsy Of Bronchus
37 31623 Diagnostic Bronchoscopy And Biopsy Of Bronchus
37 31624 Diagnostic Bronchoscopy And Biopsy Of Bronchus
37 31625 Diagnostic Bronchoscopy And Biopsy Of Bronchus
37 31626 Diagnostic Bronchoscopy And Biopsy Of Bronchus
37 31627 Diagnostic Bronchoscopy And Biopsy Of Bronchus
37 31628 Diagnostic Bronchoscopy And Biopsy Of Bronchus
37 31629 Diagnostic Bronchoscopy And Biopsy Of Bronchus
42 31630 Other Or Therapeutic Procedures On Respiratory System
42 31631 Other Or Therapeutic Procedures On Respiratory System
37 31632 Diagnostic Bronchoscopy And Biopsy Of Bronchus
37 31633 Diagnostic Bronchoscopy And Biopsy Of Bronchus
42 31634 Other Or Therapeutic Procedures On Respiratory System
229 31635 Nonoperative Removal Of Foreign Body
42 31636 Other Or Therapeutic Procedures On Respiratory System
42 31637 Other Or Therapeutic Procedures On Respiratory System
42 31638 Other Or Therapeutic Procedures On Respiratory System
42 31640 Other Or Therapeutic Procedures On Respiratory System
42 31641 Other Or Therapeutic Procedures On Respiratory System
42 31643 Other Or Therapeutic Procedures On Respiratory System
42 31645 Other Or Therapeutic Procedures On Respiratory System
42 31646 Other Or Therapeutic Procedures On Respiratory System
41 31647 Other Non-Or Therapeutic Procedures On Respiratory System
41 31648 Other Non-Or Therapeutic Procedures On Respiratory System
41 31649 Other Non-Or Therapeutic Procedures On Respiratory System
41 31651 Other Non-Or Therapeutic Procedures On Respiratory System
37 31652 Diagnostic Bronchoscopy And Biopsy Of Bronchus
37 31653 Diagnostic Bronchoscopy And Biopsy Of Bronchus
197 31654 Other Diagnostic Ultrasound
42 31660 Other Or Therapeutic Procedures On Respiratory System
42 31661 Other Or Therapeutic Procedures On Respiratory System
37 31717 Diagnostic Bronchoscopy And Biopsy Of Bronchus
42 31720 Other Or Therapeutic Procedures On Respiratory System
42 31725 Other Or Therapeutic Procedures On Respiratory System
42 31730 Other Or Therapeutic Procedures On Respiratory System
42 31750 Other Or Therapeutic Procedures On Respiratory System
42 31755 Other Or Therapeutic Procedures On Respiratory System
42 31760 Other Or Therapeutic Procedures On Respiratory System
42 31766 Other Or Therapeutic Procedures On Respiratory System
42 31770 Other Or Therapeutic Procedures On Respiratory System
42 31775 Other Or Therapeutic Procedures On Respiratory System
42 31780 Other Or Therapeutic Procedures On Respiratory System
42 31781 Other Or Therapeutic Procedures On Respiratory System
42 31785 Other Or Therapeutic Procedures On Respiratory System
42 31786 Other Or Therapeutic Procedures On Respiratory System
42 31800 Other Or Therapeutic Procedures On Respiratory System
42 31805 Other Or Therapeutic Procedures On Respiratory System
42 31820 Other Or Therapeutic Procedures On Respiratory System
42 31825 Other Or Therapeutic Procedures On Respiratory System
170 31830 Excision Of Skin Lesion
42 31899 Other Or Therapeutic Procedures On Respiratory System
39 32035 Incision Of Pleura, Thoracentesis, Chest Drainage
Blue Cross NC Proprietary and Confidential 31 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
39 32036 Incision Of Pleura, Thoracentesis, Chest Drainage
38 32096 Other Diagnostic Procedures On Lung And Bronchus
38 32097 Other Diagnostic Procedures On Lung And Bronchus
38 32098 Other Diagnostic Procedures On Lung And Bronchus
38 32100 Other Diagnostic Procedures On Lung And Bronchus
42 32110 Other Or Therapeutic Procedures On Respiratory System
42 32120 Other Or Therapeutic Procedures On Respiratory System
42 32124 Other Or Therapeutic Procedures On Respiratory System
42 32140 Other Or Therapeutic Procedures On Respiratory System
42 32141 Other Or Therapeutic Procedures On Respiratory System
42 32150 Other Or Therapeutic Procedures On Respiratory System
42 32151 Other Or Therapeutic Procedures On Respiratory System
49 32160 Other Or Heart Procedures
42 32200 Other Or Therapeutic Procedures On Respiratory System
42 32215 Other Or Therapeutic Procedures On Respiratory System
42 32220 Other Or Therapeutic Procedures On Respiratory System
42 32225 Other Or Therapeutic Procedures On Respiratory System
42 32310 Other Or Therapeutic Procedures On Respiratory System
42 32320 Other Or Therapeutic Procedures On Respiratory System
40 32400 Other Diagnostic Procedures Of Respiratory Tract And Mediastinum
38 32405 Other Diagnostic Procedures On Lung And Bronchus
36 32440 Lobectomy Or Pneumonectomy
36 32442 Lobectomy Or Pneumonectomy
36 32445 Lobectomy Or Pneumonectomy
36 32480 Lobectomy Or Pneumonectomy
36 32482 Lobectomy Or Pneumonectomy
36 32484 Lobectomy Or Pneumonectomy
36 32486 Lobectomy Or Pneumonectomy
36 32488 Lobectomy Or Pneumonectomy
36 32491 Lobectomy Or Pneumonectomy
36 32501 Lobectomy Or Pneumonectomy
42 32503 Other Or Therapeutic Procedures On Respiratory System
42 32504 Other Or Therapeutic Procedures On Respiratory System
36 32505 Lobectomy Or Pneumonectomy
36 32506 Lobectomy Or Pneumonectomy
38 32507 Other Diagnostic Procedures On Lung And Bronchus
42 32540 Other Or Therapeutic Procedures On Respiratory System
39 32550 Incision Of Pleura, Thoracentesis, Chest Drainage
39 32551 Incision Of Pleura, Thoracentesis, Chest Drainage
41 32552 Other Non-Or Therapeutic Procedures On Respiratory System
41 32553 Other Non-Or Therapeutic Procedures On Respiratory System
39 32554 Incision Of Pleura, Thoracentesis, Chest Drainage
39 32555 Incision Of Pleura, Thoracentesis, Chest Drainage
39 32556 Incision Of Pleura, Thoracentesis, Chest Drainage
39 32557 Incision Of Pleura, Thoracentesis, Chest Drainage
41 32560 Other Non-Or Therapeutic Procedures On Respiratory System
41 32561 Other Non-Or Therapeutic Procedures On Respiratory System
41 32562 Other Non-Or Therapeutic Procedures On Respiratory System
40 32601 Other Diagnostic Procedures Of Respiratory Tract And Mediastinum
62 32604 Other Diagnostic Cardiovascular Procedures
40 32606 Other Diagnostic Procedures Of Respiratory Tract And Mediastinum
38 32607 Other Diagnostic Procedures On Lung And Bronchus
38 32608 Other Diagnostic Procedures On Lung And Bronchus
38 32609 Other Diagnostic Procedures On Lung And Bronchus
42 32650 Other Or Therapeutic Procedures On Respiratory System
42 32651 Other Or Therapeutic Procedures On Respiratory System
42 32652 Other Or Therapeutic Procedures On Respiratory System
42 32653 Other Or Therapeutic Procedures On Respiratory System
42 32654 Other Or Therapeutic Procedures On Respiratory System
42 32655 Other Or Therapeutic Procedures On Respiratory System
42 32656 Other Or Therapeutic Procedures On Respiratory System
49 32658 Other Or Heart Procedures
49 32659 Other Or Heart Procedures
49 32661 Other Or Heart Procedures
42 32662 Other Or Therapeutic Procedures On Respiratory System
36 32663 Lobectomy Or Pneumonectomy
9 32664 Other Or Therapeutic Nervous System Procedures
94 32665 Other Or Upper GI Therapeutic Procedures
36 32666 Lobectomy Or Pneumonectomy
36 32667 Lobectomy Or Pneumonectomy
36 32668 Lobectomy Or Pneumonectomy
36 32669 Lobectomy Or Pneumonectomy
36 32670 Lobectomy Or Pneumonectomy
36 32671 Lobectomy Or Pneumonectomy
Blue Cross NC Proprietary and Confidential 32 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
36 32672 Lobectomy Or Pneumonectomy
12 32673 Other Therapeutic Endocrine Procedures
67 32674 Other Therapeutic Procedures, Hemic And Lymphatic System
41 32701 Other Non-Or Therapeutic Procedures On Respiratory System
42 32800 Other Or Therapeutic Procedures On Respiratory System
42 32810 Other Or Therapeutic Procedures On Respiratory System
42 32815 Other Or Therapeutic Procedures On Respiratory System
42 32820 Other Or Therapeutic Procedures On Respiratory System
36 32850 Lobectomy Or Pneumonectomy
176 32851 Other Organ Transplantation
176 32852 Other Organ Transplantation
176 32853 Other Organ Transplantation
176 32854 Other Organ Transplantation
176 32855 Other Organ Transplantation
176 32856 Other Organ Transplantation
142 32900 Partial Excision Bone
42 32905 Other Or Therapeutic Procedures On Respiratory System
42 32906 Other Or Therapeutic Procedures On Respiratory System
42 32940 Other Or Therapeutic Procedures On Respiratory System
41 32960 Other Non-Or Therapeutic Procedures On Respiratory System
42 32994 Other Or Therapeutic Procedures On Respiratory System
42 32997 Other Or Therapeutic Procedures On Respiratory System
42 32998 Other Or Therapeutic Procedures On Respiratory System
42 32999 Other Or Therapeutic Procedures On Respiratory System
63 33016 Other Non-Or Therapeutic Cardiovascular Procedures
63 33017 Other Non-Or Therapeutic Cardiovascular Procedures
63 33018 Other Non-Or Therapeutic Cardiovascular Procedures
63 33019 Other Non-Or Therapeutic Cardiovascular Procedures
49 33020 Other Or Heart Procedures
49 33025 Other Or Heart Procedures
49 33030 Other Or Heart Procedures
49 33031 Other Or Heart Procedures
49 33050 Other Or Heart Procedures
49 33120 Other Or Heart Procedures
49 33130 Other Or Heart Procedures
44 33140 Coronary Artery Bypass Graft (CABG)
44 33141 Coronary Artery Bypass Graft (CABG)
48 33202 Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 33203 Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 33206 Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 33207 Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 33208 Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 33210 Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 33211 Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 33212 Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 33213 Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 33214 Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 33215 Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 33216 Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 33217 Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 33218 Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 33220 Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 33221 Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 33222 Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 33223 Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 33224 Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 33225 Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 33226 Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 33227 Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 33228 Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 33229 Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 33230 Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 33231 Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 33233 Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 33234 Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 33235 Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 33236 Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 33237 Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 33238 Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 33240 Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 33241 Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 33243 Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 33244 Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 33249 Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
Blue Cross NC Proprietary and Confidential 33 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
49 33250 Other Or Heart Procedures
49 33251 Other Or Heart Procedures
49 33254 Other Or Heart Procedures
49 33255 Other Or Heart Procedures
49 33256 Other Or Heart Procedures
49 33257 Other Or Heart Procedures
49 33258 Other Or Heart Procedures
49 33259 Other Or Heart Procedures
49 33261 Other Or Heart Procedures
48 33262 Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 33263 Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 33264 Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
49 33265 Other Or Heart Procedures
49 33266 Other Or Heart Procedures
48 33270 Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 33271 Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 33272 Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 33273 Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 33274 Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 33275 Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 33285 Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 33286 Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 33289 Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
49 33300 Other Or Heart Procedures
49 33305 Other Or Heart Procedures
49 33310 Other Or Heart Procedures
49 33315 Other Or Heart Procedures
61 33320 Other Or Procedures On Vessels Other Than Head And Neck
61 33321 Other Or Procedures On Vessels Other Than Head And Neck
61 33322 Other Or Procedures On Vessels Other Than Head And Neck
52 33330 Aortic Resection, Replacement Or Anastomosis
52 33335 Aortic Resection, Replacement Or Anastomosis
63 33340 Other Non-Or Therapeutic Cardiovascular Procedures
43 33361 Heart Valve Procedures
43 33362 Heart Valve Procedures
43 33363 Heart Valve Procedures
43 33364 Heart Valve Procedures
43 33365 Heart Valve Procedures
43 33366 Heart Valve Procedures
43 33367 Heart Valve Procedures
43 33368 Heart Valve Procedures
43 33369 Heart Valve Procedures
43 33390 Heart Valve Procedures
43 33391 Heart Valve Procedures
43 33404 Heart Valve Procedures
43 33405 Heart Valve Procedures
43 33406 Heart Valve Procedures
43 33410 Heart Valve Procedures
43 33411 Heart Valve Procedures
43 33412 Heart Valve Procedures
43 33413 Heart Valve Procedures
43 33414 Heart Valve Procedures
43 33415 Heart Valve Procedures
43 33416 Heart Valve Procedures
43 33417 Heart Valve Procedures
43 33418 Heart Valve Procedures
43 33419 Heart Valve Procedures
43 33420 Heart Valve Procedures
43 33422 Heart Valve Procedures
43 33425 Heart Valve Procedures
43 33426 Heart Valve Procedures
43 33427 Heart Valve Procedures
43 33430 Heart Valve Procedures
52 33440 Aortic Resection, Replacement Or Anastomosis
43 33460 Heart Valve Procedures
43 33463 Heart Valve Procedures
43 33464 Heart Valve Procedures
43 33465 Heart Valve Procedures
43 33468 Heart Valve Procedures
43 33470 Heart Valve Procedures
43 33471 Heart Valve Procedures
43 33474 Heart Valve Procedures
43 33475 Heart Valve Procedures
43 33476 Heart Valve Procedures
Blue Cross NC Proprietary and Confidential 34 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
43 33477 Heart Valve Procedures
43 33478 Heart Valve Procedures
43 33496 Heart Valve Procedures
49 33500 Other Or Heart Procedures
49 33501 Other Or Heart Procedures
49 33502 Other Or Heart Procedures
49 33503 Other Or Heart Procedures
49 33504 Other Or Heart Procedures
49 33505 Other Or Heart Procedures
49 33506 Other Or Heart Procedures
49 33507 Other Or Heart Procedures
61 33508 Other Or Procedures On Vessels Other Than Head And Neck
44 33510 Coronary Artery Bypass Graft (CABG)
44 33511 Coronary Artery Bypass Graft (CABG)
44 33512 Coronary Artery Bypass Graft (CABG)
44 33513 Coronary Artery Bypass Graft (CABG)
44 33514 Coronary Artery Bypass Graft (CABG)
44 33516 Coronary Artery Bypass Graft (CABG)
44 33517 Coronary Artery Bypass Graft (CABG)
44 33518 Coronary Artery Bypass Graft (CABG)
44 33519 Coronary Artery Bypass Graft (CABG)
44 33521 Coronary Artery Bypass Graft (CABG)
44 33522 Coronary Artery Bypass Graft (CABG)
44 33523 Coronary Artery Bypass Graft (CABG)
44 33530 Coronary Artery Bypass Graft (CABG)
44 33533 Coronary Artery Bypass Graft (CABG)
44 33534 Coronary Artery Bypass Graft (CABG)
44 33535 Coronary Artery Bypass Graft (CABG)
44 33536 Coronary Artery Bypass Graft (CABG)
49 33542 Other Or Heart Procedures
49 33545 Other Or Heart Procedures
49 33548 Other Or Heart Procedures
49 33572 Other Or Heart Procedures
43 33600 Heart Valve Procedures
43 33602 Heart Valve Procedures
52 33606 Aortic Resection, Replacement Or Anastomosis
49 33608 Other Or Heart Procedures
49 33610 Other Or Heart Procedures
49 33611 Other Or Heart Procedures
49 33612 Other Or Heart Procedures
49 33615 Other Or Heart Procedures
49 33617 Other Or Heart Procedures
49 33619 Other Or Heart Procedures
49 33620 Other Or Heart Procedures
49 33621 Other Or Heart Procedures
49 33622 Other Or Heart Procedures
49 33641 Other Or Heart Procedures
49 33645 Other Or Heart Procedures
49 33647 Other Or Heart Procedures
49 33660 Other Or Heart Procedures
49 33665 Other Or Heart Procedures
49 33670 Other Or Heart Procedures
49 33675 Other Or Heart Procedures
49 33676 Other Or Heart Procedures
49 33677 Other Or Heart Procedures
49 33681 Other Or Heart Procedures
43 33684 Heart Valve Procedures
49 33688 Other Or Heart Procedures
61 33690 Other Or Procedures On Vessels Other Than Head And Neck
49 33692 Other Or Heart Procedures
49 33694 Other Or Heart Procedures
49 33697 Other Or Heart Procedures
49 33702 Other Or Heart Procedures
49 33710 Other Or Heart Procedures
49 33720 Other Or Heart Procedures
49 33722 Other Or Heart Procedures
49 33724 Other Or Heart Procedures
49 33726 Other Or Heart Procedures
49 33730 Other Or Heart Procedures
43 33732 Heart Valve Procedures
49 33735 Other Or Heart Procedures
49 33736 Other Or Heart Procedures
49 33737 Other Or Heart Procedures
56 33750 Other Vascular Bypass And Shunt, Not Heart
Blue Cross NC Proprietary and Confidential 35 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
56 33755 Other Vascular Bypass And Shunt, Not Heart
56 33762 Other Vascular Bypass And Shunt, Not Heart
56 33764 Other Vascular Bypass And Shunt, Not Heart
56 33766 Other Vascular Bypass And Shunt, Not Heart
56 33767 Other Vascular Bypass And Shunt, Not Heart
56 33768 Other Vascular Bypass And Shunt, Not Heart
49 33770 Other Or Heart Procedures
49 33771 Other Or Heart Procedures
49 33774 Other Or Heart Procedures
49 33775 Other Or Heart Procedures
49 33776 Other Or Heart Procedures
49 33777 Other Or Heart Procedures
49 33778 Other Or Heart Procedures
49 33779 Other Or Heart Procedures
49 33780 Other Or Heart Procedures
49 33781 Other Or Heart Procedures
49 33782 Other Or Heart Procedures
49 33783 Other Or Heart Procedures
49 33786 Other Or Heart Procedures
61 33788 Other Or Procedures On Vessels Other Than Head And Neck
61 33800 Other Or Procedures On Vessels Other Than Head And Neck
52 33802 Aortic Resection, Replacement Or Anastomosis
52 33803 Aortic Resection, Replacement Or Anastomosis
49 33813 Other Or Heart Procedures
49 33814 Other Or Heart Procedures
52 33820 Aortic Resection, Replacement Or Anastomosis
52 33822 Aortic Resection, Replacement Or Anastomosis
52 33824 Aortic Resection, Replacement Or Anastomosis
52 33840 Aortic Resection, Replacement Or Anastomosis
52 33845 Aortic Resection, Replacement Or Anastomosis
52 33851 Aortic Resection, Replacement Or Anastomosis
52 33852 Aortic Resection, Replacement Or Anastomosis
52 33853 Aortic Resection, Replacement Or Anastomosis
52 33858 Aortic Resection, Replacement Or Anastomosis
52 33859 Aortic Resection, Replacement Or Anastomosis
52 33863 Aortic Resection, Replacement Or Anastomosis
52 33864 Aortic Resection, Replacement Or Anastomosis
52 33866 Aortic Resection, Replacement Or Anastomosis
52 33871 Aortic Resection, Replacement Or Anastomosis
52 33875 Aortic Resection, Replacement Or Anastomosis
52 33877 Aortic Resection, Replacement Or Anastomosis
52 33880 Aortic Resection, Replacement Or Anastomosis
52 33881 Aortic Resection, Replacement Or Anastomosis
52 33883 Aortic Resection, Replacement Or Anastomosis
52 33884 Aortic Resection, Replacement Or Anastomosis
52 33886 Aortic Resection, Replacement Or Anastomosis
59 33889 Other Or Procedures On Vessels Of Head And Neck
59 33891 Other Or Procedures On Vessels Of Head And Neck
61 33910 Other Or Procedures On Vessels Other Than Head And Neck
61 33915 Other Or Procedures On Vessels Other Than Head And Neck
61 33916 Other Or Procedures On Vessels Other Than Head And Neck
61 33917 Other Or Procedures On Vessels Other Than Head And Neck
43 33920 Heart Valve Procedures
61 33922 Other Or Procedures On Vessels Other Than Head And Neck
49 33924 Other Or Heart Procedures
61 33925 Other Or Procedures On Vessels Other Than Head And Neck
61 33926 Other Or Procedures On Vessels Other Than Head And Neck
49 33927 Other Or Heart Procedures
49 33928 Other Or Heart Procedures
49 33929 Other Or Heart Procedures
176 33930 Other Organ Transplantation
176 33933 Other Organ Transplantation
176 33935 Other Organ Transplantation
49 33940 Other Or Heart Procedures
176 33944 Other Organ Transplantation
176 33945 Other Organ Transplantation
50 33946 Extracorporeal Circulation Auxiliary To Open Heart Procedures
50 33947 Extracorporeal Circulation Auxiliary To Open Heart Procedures
50 33948 Extracorporeal Circulation Auxiliary To Open Heart Procedures
50 33949 Extracorporeal Circulation Auxiliary To Open Heart Procedures
50 33951 Extracorporeal Circulation Auxiliary To Open Heart Procedures
50 33952 Extracorporeal Circulation Auxiliary To Open Heart Procedures
50 33953 Extracorporeal Circulation Auxiliary To Open Heart Procedures
50 33954 Extracorporeal Circulation Auxiliary To Open Heart Procedures
Blue Cross NC Proprietary and Confidential 36 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
50 33955 Extracorporeal Circulation Auxiliary To Open Heart Procedures
50 33956 Extracorporeal Circulation Auxiliary To Open Heart Procedures
50 33957 Extracorporeal Circulation Auxiliary To Open Heart Procedures
50 33958 Extracorporeal Circulation Auxiliary To Open Heart Procedures
50 33959 Extracorporeal Circulation Auxiliary To Open Heart Procedures
50 33962 Extracorporeal Circulation Auxiliary To Open Heart Procedures
50 33963 Extracorporeal Circulation Auxiliary To Open Heart Procedures
50 33964 Extracorporeal Circulation Auxiliary To Open Heart Procedures
50 33965 Extracorporeal Circulation Auxiliary To Open Heart Procedures
50 33966 Extracorporeal Circulation Auxiliary To Open Heart Procedures
49 33967 Other Or Heart Procedures
49 33968 Other Or Heart Procedures
50 33969 Extracorporeal Circulation Auxiliary To Open Heart Procedures
49 33970 Other Or Heart Procedures
49 33971 Other Or Heart Procedures
49 33973 Other Or Heart Procedures
49 33974 Other Or Heart Procedures
49 33975 Other Or Heart Procedures
49 33976 Other Or Heart Procedures
49 33977 Other Or Heart Procedures
49 33978 Other Or Heart Procedures
49 33979 Other Or Heart Procedures
49 33980 Other Or Heart Procedures
49 33981 Other Or Heart Procedures
49 33982 Other Or Heart Procedures
49 33983 Other Or Heart Procedures
50 33984 Extracorporeal Circulation Auxiliary To Open Heart Procedures
50 33985 Extracorporeal Circulation Auxiliary To Open Heart Procedures
50 33986 Extracorporeal Circulation Auxiliary To Open Heart Procedures
50 33987 Extracorporeal Circulation Auxiliary To Open Heart Procedures
50 33988 Extracorporeal Circulation Auxiliary To Open Heart Procedures
50 33989 Extracorporeal Circulation Auxiliary To Open Heart Procedures
50 33990 Extracorporeal Circulation Auxiliary To Open Heart Procedures
50 33991 Extracorporeal Circulation Auxiliary To Open Heart Procedures
50 33992 Extracorporeal Circulation Auxiliary To Open Heart Procedures
50 33993 Extracorporeal Circulation Auxiliary To Open Heart Procedures
49 33999 Other Or Heart Procedures
59 34001 Other Or Procedures On Vessels Of Head And Neck
61 34051 Other Or Procedures On Vessels Other Than Head And Neck
61 34101 Other Or Procedures On Vessels Other Than Head And Neck
61 34111 Other Or Procedures On Vessels Other Than Head And Neck
61 34151 Other Or Procedures On Vessels Other Than Head And Neck
60 34201 Embolectomy And Endarterectomy Of Lower Limbs
60 34203 Embolectomy And Endarterectomy Of Lower Limbs
61 34401 Other Or Procedures On Vessels Other Than Head And Neck
60 34421 Embolectomy And Endarterectomy Of Lower Limbs
60 34451 Embolectomy And Endarterectomy Of Lower Limbs
59 34471 Other Or Procedures On Vessels Of Head And Neck
61 34490 Other Or Procedures On Vessels Other Than Head And Neck
61 34501 Other Or Procedures On Vessels Other Than Head And Neck
61 34502 Other Or Procedures On Vessels Other Than Head And Neck
61 34510 Other Or Procedures On Vessels Other Than Head And Neck
55 34520 Peripheral Vascular Bypass
61 34530 Other Or Procedures On Vessels Other Than Head And Neck
61 34701 Other Or Procedures On Vessels Other Than Head And Neck
61 34702 Other Or Procedures On Vessels Other Than Head And Neck
61 34703 Other Or Procedures On Vessels Other Than Head And Neck
61 34704 Other Or Procedures On Vessels Other Than Head And Neck
61 34705 Other Or Procedures On Vessels Other Than Head And Neck
61 34706 Other Or Procedures On Vessels Other Than Head And Neck
61 34707 Other Or Procedures On Vessels Other Than Head And Neck
61 34708 Other Or Procedures On Vessels Other Than Head And Neck
61 34709 Other Or Procedures On Vessels Other Than Head And Neck
61 34710 Other Or Procedures On Vessels Other Than Head And Neck
61 34711 Other Or Procedures On Vessels Other Than Head And Neck
61 34712 Other Or Procedures On Vessels Other Than Head And Neck
61 34713 Other Or Procedures On Vessels Other Than Head And Neck
61 34714 Other Or Procedures On Vessels Other Than Head And Neck
61 34715 Other Or Procedures On Vessels Other Than Head And Neck
61 34716 Other Or Procedures On Vessels Other Than Head And Neck
52 34717 Aortic Resection, Replacement Or Anastomosis
52 34718 Aortic Resection, Replacement Or Anastomosis
61 34808 Other Or Procedures On Vessels Other Than Head And Neck
61 34812 Other Or Procedures On Vessels Other Than Head And Neck
Blue Cross NC Proprietary and Confidential 37 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
61 34813 Other Or Procedures On Vessels Other Than Head And Neck
61 34820 Other Or Procedures On Vessels Other Than Head And Neck
52 34830 Aortic Resection, Replacement Or Anastomosis
52 34831 Aortic Resection, Replacement Or Anastomosis
52 34832 Aortic Resection, Replacement Or Anastomosis
61 34833 Other Or Procedures On Vessels Other Than Head And Neck
61 34834 Other Or Procedures On Vessels Other Than Head And Neck
52 34839 Aortic Resection, Replacement Or Anastomosis
61 34841 Other Or Procedures On Vessels Other Than Head And Neck
61 34842 Other Or Procedures On Vessels Other Than Head And Neck
61 34843 Other Or Procedures On Vessels Other Than Head And Neck
61 34844 Other Or Procedures On Vessels Other Than Head And Neck
61 34845 Other Or Procedures On Vessels Other Than Head And Neck
61 34846 Other Or Procedures On Vessels Other Than Head And Neck
61 34847 Other Or Procedures On Vessels Other Than Head And Neck
61 34848 Other Or Procedures On Vessels Other Than Head And Neck
59 35001 Other Or Procedures On Vessels Of Head And Neck
59 35002 Other Or Procedures On Vessels Of Head And Neck
59 35005 Other Or Procedures On Vessels Of Head And Neck
61 35011 Other Or Procedures On Vessels Other Than Head And Neck
61 35013 Other Or Procedures On Vessels Other Than Head And Neck
61 35021 Other Or Procedures On Vessels Other Than Head And Neck
61 35022 Other Or Procedures On Vessels Other Than Head And Neck
61 35045 Other Or Procedures On Vessels Other Than Head And Neck
52 35081 Aortic Resection, Replacement Or Anastomosis
52 35082 Aortic Resection, Replacement Or Anastomosis
52 35091 Aortic Resection, Replacement Or Anastomosis
52 35092 Aortic Resection, Replacement Or Anastomosis
52 35102 Aortic Resection, Replacement Or Anastomosis
52 35103 Aortic Resection, Replacement Or Anastomosis
61 35111 Other Or Procedures On Vessels Other Than Head And Neck
61 35112 Other Or Procedures On Vessels Other Than Head And Neck
61 35121 Other Or Procedures On Vessels Other Than Head And Neck
61 35122 Other Or Procedures On Vessels Other Than Head And Neck
61 35131 Other Or Procedures On Vessels Other Than Head And Neck
61 35132 Other Or Procedures On Vessels Other Than Head And Neck
61 35141 Other Or Procedures On Vessels Other Than Head And Neck
61 35142 Other Or Procedures On Vessels Other Than Head And Neck
61 35151 Other Or Procedures On Vessels Other Than Head And Neck
61 35152 Other Or Procedures On Vessels Other Than Head And Neck
59 35180 Other Or Procedures On Vessels Of Head And Neck
61 35182 Other Or Procedures On Vessels Other Than Head And Neck
61 35184 Other Or Procedures On Vessels Other Than Head And Neck
59 35188 Other Or Procedures On Vessels Of Head And Neck
61 35189 Other Or Procedures On Vessels Other Than Head And Neck
61 35190 Other Or Procedures On Vessels Other Than Head And Neck
61 35201 Other Or Procedures On Vessels Other Than Head And Neck
61 35206 Other Or Procedures On Vessels Other Than Head And Neck
61 35207 Other Or Procedures On Vessels Other Than Head And Neck
61 35211 Other Or Procedures On Vessels Other Than Head And Neck
61 35216 Other Or Procedures On Vessels Other Than Head And Neck
61 35221 Other Or Procedures On Vessels Other Than Head And Neck
61 35226 Other Or Procedures On Vessels Other Than Head And Neck
59 35231 Other Or Procedures On Vessels Of Head And Neck
61 35236 Other Or Procedures On Vessels Other Than Head And Neck
61 35241 Other Or Procedures On Vessels Other Than Head And Neck
61 35246 Other Or Procedures On Vessels Other Than Head And Neck
61 35251 Other Or Procedures On Vessels Other Than Head And Neck
61 35256 Other Or Procedures On Vessels Other Than Head And Neck
59 35261 Other Or Procedures On Vessels Of Head And Neck
59 35266 Other Or Procedures On Vessels Of Head And Neck
61 35271 Other Or Procedures On Vessels Other Than Head And Neck
61 35276 Other Or Procedures On Vessels Other Than Head And Neck
61 35281 Other Or Procedures On Vessels Other Than Head And Neck
61 35286 Other Or Procedures On Vessels Other Than Head And Neck
51 35301 Endarterectomy, Vessel Of Head And Neck
60 35302 Embolectomy And Endarterectomy Of Lower Limbs
60 35303 Embolectomy And Endarterectomy Of Lower Limbs
60 35304 Embolectomy And Endarterectomy Of Lower Limbs
60 35305 Embolectomy And Endarterectomy Of Lower Limbs
60 35306 Embolectomy And Endarterectomy Of Lower Limbs
61 35311 Other Or Procedures On Vessels Other Than Head And Neck
61 35321 Other Or Procedures On Vessels Other Than Head And Neck
61 35331 Other Or Procedures On Vessels Other Than Head And Neck
Blue Cross NC Proprietary and Confidential 38 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
61 35341 Other Or Procedures On Vessels Other Than Head And Neck
61 35351 Other Or Procedures On Vessels Other Than Head And Neck
60 35355 Embolectomy And Endarterectomy Of Lower Limbs
60 35361 Embolectomy And Endarterectomy Of Lower Limbs
60 35363 Embolectomy And Endarterectomy Of Lower Limbs
60 35371 Embolectomy And Endarterectomy Of Lower Limbs
60 35372 Embolectomy And Endarterectomy Of Lower Limbs
51 35390 Endarterectomy, Vessel Of Head And Neck
62 35400 Other Diagnostic Cardiovascular Procedures
61 35500 Other Or Procedures On Vessels Other Than Head And Neck
56 35501 Other Vascular Bypass And Shunt, Not Heart
56 35506 Other Vascular Bypass And Shunt, Not Heart
56 35508 Other Vascular Bypass And Shunt, Not Heart
56 35509 Other Vascular Bypass And Shunt, Not Heart
56 35510 Other Vascular Bypass And Shunt, Not Heart
56 35511 Other Vascular Bypass And Shunt, Not Heart
56 35512 Other Vascular Bypass And Shunt, Not Heart
56 35515 Other Vascular Bypass And Shunt, Not Heart
55 35516 Peripheral Vascular Bypass
55 35518 Peripheral Vascular Bypass
55 35521 Peripheral Vascular Bypass
55 35522 Peripheral Vascular Bypass
55 35523 Peripheral Vascular Bypass
55 35525 Peripheral Vascular Bypass
56 35526 Other Vascular Bypass And Shunt, Not Heart
56 35531 Other Vascular Bypass And Shunt, Not Heart
55 35533 Peripheral Vascular Bypass
56 35535 Other Vascular Bypass And Shunt, Not Heart
56 35536 Other Vascular Bypass And Shunt, Not Heart
55 35537 Peripheral Vascular Bypass
55 35538 Peripheral Vascular Bypass
55 35539 Peripheral Vascular Bypass
55 35540 Peripheral Vascular Bypass
55 35556 Peripheral Vascular Bypass
55 35558 Peripheral Vascular Bypass
56 35560 Other Vascular Bypass And Shunt, Not Heart
56 35563 Other Vascular Bypass And Shunt, Not Heart
55 35565 Peripheral Vascular Bypass
55 35566 Peripheral Vascular Bypass
55 35570 Peripheral Vascular Bypass
55 35571 Peripheral Vascular Bypass
61 35572 Other Or Procedures On Vessels Other Than Head And Neck
55 35583 Peripheral Vascular Bypass
55 35585 Peripheral Vascular Bypass
55 35587 Peripheral Vascular Bypass
44 35600 Coronary Artery Bypass Graft (CABG)
56 35601 Other Vascular Bypass And Shunt, Not Heart
56 35606 Other Vascular Bypass And Shunt, Not Heart
56 35612 Other Vascular Bypass And Shunt, Not Heart
55 35616 Peripheral Vascular Bypass
55 35621 Peripheral Vascular Bypass
55 35623 Peripheral Vascular Bypass
56 35626 Other Vascular Bypass And Shunt, Not Heart
56 35631 Other Vascular Bypass And Shunt, Not Heart
56 35632 Other Vascular Bypass And Shunt, Not Heart
56 35633 Other Vascular Bypass And Shunt, Not Heart
56 35634 Other Vascular Bypass And Shunt, Not Heart
56 35636 Other Vascular Bypass And Shunt, Not Heart
55 35637 Peripheral Vascular Bypass
55 35638 Peripheral Vascular Bypass
56 35642 Other Vascular Bypass And Shunt, Not Heart
56 35645 Other Vascular Bypass And Shunt, Not Heart
55 35646 Peripheral Vascular Bypass
55 35647 Peripheral Vascular Bypass
55 35650 Peripheral Vascular Bypass
55 35654 Peripheral Vascular Bypass
55 35656 Peripheral Vascular Bypass
55 35661 Peripheral Vascular Bypass
56 35663 Other Vascular Bypass And Shunt, Not Heart
55 35665 Peripheral Vascular Bypass
55 35666 Peripheral Vascular Bypass
55 35671 Peripheral Vascular Bypass
61 35681 Other Or Procedures On Vessels Other Than Head And Neck
61 35682 Other Or Procedures On Vessels Other Than Head And Neck
Blue Cross NC Proprietary and Confidential 39 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
61 35683 Other Or Procedures On Vessels Other Than Head And Neck
55 35685 Peripheral Vascular Bypass
55 35686 Peripheral Vascular Bypass
59 35691 Other Or Procedures On Vessels Of Head And Neck
59 35693 Other Or Procedures On Vessels Of Head And Neck
59 35694 Other Or Procedures On Vessels Of Head And Neck
59 35695 Other Or Procedures On Vessels Of Head And Neck
59 35697 Other Or Procedures On Vessels Of Head And Neck
60 35700 Embolectomy And Endarterectomy Of Lower Limbs
59 35701 Other Or Procedures On Vessels Of Head And Neck
61 35702 Other Or Procedures On Vessels Other Than Head And Neck
61 35703 Other Or Procedures On Vessels Other Than Head And Neck
59 35800 Other Or Procedures On Vessels Of Head And Neck
61 35820 Other Or Procedures On Vessels Other Than Head And Neck
61 35840 Other Or Procedures On Vessels Other Than Head And Neck
61 35860 Other Or Procedures On Vessels Other Than Head And Neck
61 35870 Other Or Procedures On Vessels Other Than Head And Neck
61 35875 Other Or Procedures On Vessels Other Than Head And Neck
61 35876 Other Or Procedures On Vessels Other Than Head And Neck
61 35879 Other Or Procedures On Vessels Other Than Head And Neck
61 35881 Other Or Procedures On Vessels Other Than Head And Neck
61 35883 Other Or Procedures On Vessels Other Than Head And Neck
61 35884 Other Or Procedures On Vessels Other Than Head And Neck
51 35901 Endarterectomy, Vessel Of Head And Neck
60 35903 Embolectomy And Endarterectomy Of Lower Limbs
61 35905 Other Or Procedures On Vessels Other Than Head And Neck
61 35907 Other Or Procedures On Vessels Other Than Head And Neck
54 36000 Other Vascular Catheterization, Not Heart
63 36002 Other Non-Or Therapeutic Cardiovascular Procedures
62 36005 Other Diagnostic Cardiovascular Procedures
54 36010 Other Vascular Catheterization, Not Heart
54 36011 Other Vascular Catheterization, Not Heart
54 36012 Other Vascular Catheterization, Not Heart
47 36013 Diagnostic Cardiac Catheterization, Coronary Arteriography
54 36014 Other Vascular Catheterization, Not Heart
54 36015 Other Vascular Catheterization, Not Heart
54 36100 Other Vascular Catheterization, Not Heart
54 36140 Other Vascular Catheterization, Not Heart
54 36160 Other Vascular Catheterization, Not Heart
54 36200 Other Vascular Catheterization, Not Heart
54 36215 Other Vascular Catheterization, Not Heart
54 36216 Other Vascular Catheterization, Not Heart
54 36217 Other Vascular Catheterization, Not Heart
54 36218 Other Vascular Catheterization, Not Heart
54 36221 Other Vascular Catheterization, Not Heart
54 36222 Other Vascular Catheterization, Not Heart
54 36223 Other Vascular Catheterization, Not Heart
54 36224 Other Vascular Catheterization, Not Heart
54 36225 Other Vascular Catheterization, Not Heart
54 36226 Other Vascular Catheterization, Not Heart
54 36227 Other Vascular Catheterization, Not Heart
54 36228 Other Vascular Catheterization, Not Heart
54 36245 Other Vascular Catheterization, Not Heart
54 36246 Other Vascular Catheterization, Not Heart
54 36247 Other Vascular Catheterization, Not Heart
54 36248 Other Vascular Catheterization, Not Heart
54 36251 Other Vascular Catheterization, Not Heart
54 36252 Other Vascular Catheterization, Not Heart
54 36253 Other Vascular Catheterization, Not Heart
54 36254 Other Vascular Catheterization, Not Heart
61 36260 Other Or Procedures On Vessels Other Than Head And Neck
61 36261 Other Or Procedures On Vessels Other Than Head And Neck
61 36262 Other Or Procedures On Vessels Other Than Head And Neck
231 36299 Other Therapeutic Procedures
231 36400 Other Therapeutic Procedures
231 36405 Other Therapeutic Procedures
231 36406 Other Therapeutic Procedures
231 36410 Other Therapeutic Procedures
T1A 36415 Lab Tests - Routine Venipuncture (Non-Medicare Fee Schedule)
T1A 36416 Lab Tests - Routine Venipuncture (Non-Medicare Fee Schedule)
63 36420 Other Non-Or Therapeutic Cardiovascular Procedures
63 36425 Other Non-Or Therapeutic Cardiovascular Procedures
222 36430 Blood Transfusion
222 36440 Blood Transfusion
Blue Cross NC Proprietary and Confidential 40 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
222 36450 Blood Transfusion
222 36455 Blood Transfusion
222 36456 Blood Transfusion
141 36460 Other Therapeutic Obstetrical Procedures
61 36465 Other Or Procedures On Vessels Other Than Head And Neck
61 36466 Other Or Procedures On Vessels Other Than Head And Neck
63 36468 Other Non-Or Therapeutic Cardiovascular Procedures
61 36470 Other Or Procedures On Vessels Other Than Head And Neck
61 36471 Other Or Procedures On Vessels Other Than Head And Neck
63 36473 Other Non-Or Therapeutic Cardiovascular Procedures
63 36474 Other Non-Or Therapeutic Cardiovascular Procedures
63 36475 Other Non-Or Therapeutic Cardiovascular Procedures
63 36476 Other Non-Or Therapeutic Cardiovascular Procedures
63 36478 Other Non-Or Therapeutic Cardiovascular Procedures
63 36479 Other Non-Or Therapeutic Cardiovascular Procedures
54 36481 Other Vascular Catheterization, Not Heart
61 36482 Other Or Procedures On Vessels Other Than Head And Neck
61 36483 Other Or Procedures On Vessels Other Than Head And Neck
54 36500 Other Vascular Catheterization, Not Heart
54 36510 Other Vascular Catheterization, Not Heart
231 36511 Other Therapeutic Procedures
231 36512 Other Therapeutic Procedures
231 36513 Other Therapeutic Procedures
231 36514 Other Therapeutic Procedures
231 36516 Other Therapeutic Procedures
231 36522 Other Therapeutic Procedures
54 36555 Other Vascular Catheterization, Not Heart
54 36556 Other Vascular Catheterization, Not Heart
54 36557 Other Vascular Catheterization, Not Heart
54 36558 Other Vascular Catheterization, Not Heart
54 36560 Other Vascular Catheterization, Not Heart
54 36561 Other Vascular Catheterization, Not Heart
54 36563 Other Vascular Catheterization, Not Heart
54 36565 Other Vascular Catheterization, Not Heart
54 36566 Other Vascular Catheterization, Not Heart
54 36568 Other Vascular Catheterization, Not Heart
54 36569 Other Vascular Catheterization, Not Heart
54 36570 Other Vascular Catheterization, Not Heart
54 36571 Other Vascular Catheterization, Not Heart
54 36572 Other Vascular Catheterization, Not Heart
54 36573 Other Vascular Catheterization, Not Heart
63 36575 Other Non-Or Therapeutic Cardiovascular Procedures
63 36576 Other Non-Or Therapeutic Cardiovascular Procedures
54 36578 Other Vascular Catheterization, Not Heart
54 36580 Other Vascular Catheterization, Not Heart
54 36581 Other Vascular Catheterization, Not Heart
54 36582 Other Vascular Catheterization, Not Heart
54 36583 Other Vascular Catheterization, Not Heart
54 36584 Other Vascular Catheterization, Not Heart
54 36585 Other Vascular Catheterization, Not Heart
63 36589 Other Non-Or Therapeutic Cardiovascular Procedures
63 36590 Other Non-Or Therapeutic Cardiovascular Procedures
63 36591 Other Non-Or Therapeutic Cardiovascular Procedures
63 36592 Other Non-Or Therapeutic Cardiovascular Procedures
63 36593 Other Non-Or Therapeutic Cardiovascular Procedures
54 36595 Other Vascular Catheterization, Not Heart
63 36596 Other Non-Or Therapeutic Cardiovascular Procedures
54 36597 Other Vascular Catheterization, Not Heart
226 36598 Other Diagnostic Radiology And Related Techniques
231 36600 Other Therapeutic Procedures
54 36620 Other Vascular Catheterization, Not Heart
54 36625 Other Vascular Catheterization, Not Heart
54 36640 Other Vascular Catheterization, Not Heart
54 36660 Other Vascular Catheterization, Not Heart
67 36680 Other Therapeutic Procedures, Hemic And Lymphatic System
57 36800 Creation, Revision And Removal Of Arteriovenous Fistula Or Vessel-To-Vessel Cannula For
57 36810 Creation, Revision And Removal Of Arteriovenous Fistula Or Vessel-To-Vessel Cannula For
57 36815 Creation, Revision And Removal Of Arteriovenous Fistula Or Vessel-To-Vessel Cannula For
57 36818 Creation, Revision And Removal Of Arteriovenous Fistula Or Vessel-To-Vessel Cannula For
57 36819 Creation, Revision And Removal Of Arteriovenous Fistula Or Vessel-To-Vessel Cannula For
57 36820 Creation, Revision And Removal Of Arteriovenous Fistula Or Vessel-To-Vessel Cannula For
57 36821 Creation, Revision And Removal Of Arteriovenous Fistula Or Vessel-To-Vessel Cannula For
54 36823 Other Vascular Catheterization, Not Heart
57 36825 Creation, Revision And Removal Of Arteriovenous Fistula Or Vessel-To-Vessel Cannula For
Blue Cross NC Proprietary and Confidential 41 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
57 36830 Creation, Revision And Removal Of Arteriovenous Fistula Or Vessel-To-Vessel Cannula For
61 36831 Other Or Procedures On Vessels Other Than Head And Neck
57 36832 Creation, Revision And Removal Of Arteriovenous Fistula Or Vessel-To-Vessel Cannula For
57 36833 Creation, Revision And Removal Of Arteriovenous Fistula Or Vessel-To-Vessel Cannula For
57 36835 Creation, Revision And Removal Of Arteriovenous Fistula Or Vessel-To-Vessel Cannula For
63 36838 Other Non-Or Therapeutic Cardiovascular Procedures
61 36860 Other Or Procedures On Vessels Other Than Head And Neck
61 36861 Other Or Procedures On Vessels Other Than Head And Neck
57 36901 Creation, Revision And Removal Of Arteriovenous Fistula Or Vessel-To-Vessel Cannula For
57 36902 Creation, Revision And Removal Of Arteriovenous Fistula Or Vessel-To-Vessel Cannula For
57 36903 Creation, Revision And Removal Of Arteriovenous Fistula Or Vessel-To-Vessel Cannula For
57 36904 Creation, Revision And Removal Of Arteriovenous Fistula Or Vessel-To-Vessel Cannula For
57 36905 Creation, Revision And Removal Of Arteriovenous Fistula Or Vessel-To-Vessel Cannula For
57 36906 Creation, Revision And Removal Of Arteriovenous Fistula Or Vessel-To-Vessel Cannula For
57 36907 Creation, Revision And Removal Of Arteriovenous Fistula Or Vessel-To-Vessel Cannula For
57 36908 Creation, Revision And Removal Of Arteriovenous Fistula Or Vessel-To-Vessel Cannula For
57 36909 Creation, Revision And Removal Of Arteriovenous Fistula Or Vessel-To-Vessel Cannula For
56 37140 Other Vascular Bypass And Shunt, Not Heart
56 37145 Other Vascular Bypass And Shunt, Not Heart
56 37160 Other Vascular Bypass And Shunt, Not Heart
56 37180 Other Vascular Bypass And Shunt, Not Heart
56 37181 Other Vascular Bypass And Shunt, Not Heart
56 37182 Other Vascular Bypass And Shunt, Not Heart
56 37183 Other Vascular Bypass And Shunt, Not Heart
61 37184 Other Or Procedures On Vessels Other Than Head And Neck
61 37185 Other Or Procedures On Vessels Other Than Head And Neck
61 37186 Other Or Procedures On Vessels Other Than Head And Neck
61 37187 Other Or Procedures On Vessels Other Than Head And Neck
61 37188 Other Or Procedures On Vessels Other Than Head And Neck
63 37191 Other Non-Or Therapeutic Cardiovascular Procedures
63 37192 Other Non-Or Therapeutic Cardiovascular Procedures
63 37193 Other Non-Or Therapeutic Cardiovascular Procedures
63 37195 Other Non-Or Therapeutic Cardiovascular Procedures
54 37197 Other Vascular Catheterization, Not Heart
62 37200 Other Diagnostic Cardiovascular Procedures
54 37211 Other Vascular Catheterization, Not Heart
61 37212 Other Or Procedures On Vessels Other Than Head And Neck
61 37213 Other Or Procedures On Vessels Other Than Head And Neck
61 37214 Other Or Procedures On Vessels Other Than Head And Neck
59 37215 Other Or Procedures On Vessels Of Head And Neck
59 37216 Other Or Procedures On Vessels Of Head And Neck
61 37217 Other Or Procedures On Vessels Other Than Head And Neck
61 37218 Other Or Procedures On Vessels Other Than Head And Neck
61 37220 Other Or Procedures On Vessels Other Than Head And Neck
61 37221 Other Or Procedures On Vessels Other Than Head And Neck
61 37222 Other Or Procedures On Vessels Other Than Head And Neck
61 37223 Other Or Procedures On Vessels Other Than Head And Neck
61 37224 Other Or Procedures On Vessels Other Than Head And Neck
61 37225 Other Or Procedures On Vessels Other Than Head And Neck
61 37226 Other Or Procedures On Vessels Other Than Head And Neck
61 37227 Other Or Procedures On Vessels Other Than Head And Neck
61 37228 Other Or Procedures On Vessels Other Than Head And Neck
61 37229 Other Or Procedures On Vessels Other Than Head And Neck
61 37230 Other Or Procedures On Vessels Other Than Head And Neck
61 37231 Other Or Procedures On Vessels Other Than Head And Neck
61 37232 Other Or Procedures On Vessels Other Than Head And Neck
61 37233 Other Or Procedures On Vessels Other Than Head And Neck
61 37234 Other Or Procedures On Vessels Other Than Head And Neck
61 37235 Other Or Procedures On Vessels Other Than Head And Neck
61 37236 Other Or Procedures On Vessels Other Than Head And Neck
61 37237 Other Or Procedures On Vessels Other Than Head And Neck
61 37238 Other Or Procedures On Vessels Other Than Head And Neck
61 37239 Other Or Procedures On Vessels Other Than Head And Neck
61 37241 Other Or Procedures On Vessels Other Than Head And Neck
61 37242 Other Or Procedures On Vessels Other Than Head And Neck
61 37243 Other Or Procedures On Vessels Other Than Head And Neck
61 37244 Other Or Procedures On Vessels Other Than Head And Neck
61 37246 Other Or Procedures On Vessels Other Than Head And Neck
61 37247 Other Or Procedures On Vessels Other Than Head And Neck
61 37248 Other Or Procedures On Vessels Other Than Head And Neck
61 37249 Other Or Procedures On Vessels Other Than Head And Neck
197 37252 Other Diagnostic Ultrasound
197 37253 Other Diagnostic Ultrasound
61 37500 Other Or Procedures On Vessels Other Than Head And Neck
Blue Cross NC Proprietary and Confidential 42 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
62 37501 Other Diagnostic Cardiovascular Procedures
59 37565 Other Or Procedures On Vessels Of Head And Neck
59 37600 Other Or Procedures On Vessels Of Head And Neck
59 37605 Other Or Procedures On Vessels Of Head And Neck
59 37606 Other Or Procedures On Vessels Of Head And Neck
59 37607 Other Or Procedures On Vessels Of Head And Neck
59 37609 Other Or Procedures On Vessels Of Head And Neck
59 37615 Other Or Procedures On Vessels Of Head And Neck
61 37616 Other Or Procedures On Vessels Other Than Head And Neck
61 37617 Other Or Procedures On Vessels Other Than Head And Neck
61 37618 Other Or Procedures On Vessels Other Than Head And Neck
61 37619 Other Or Procedures On Vessels Other Than Head And Neck
61 37650 Other Or Procedures On Vessels Other Than Head And Neck
61 37660 Other Or Procedures On Vessels Other Than Head And Neck
53 37700 Varicose Vein Stripping, Lower Limb
53 37718 Varicose Vein Stripping, Lower Limb
53 37722 Varicose Vein Stripping, Lower Limb
53 37735 Varicose Vein Stripping, Lower Limb
53 37760 Varicose Vein Stripping, Lower Limb
53 37761 Varicose Vein Stripping, Lower Limb
53 37765 Varicose Vein Stripping, Lower Limb
53 37766 Varicose Vein Stripping, Lower Limb
53 37780 Varicose Vein Stripping, Lower Limb
53 37785 Varicose Vein Stripping, Lower Limb
61 37788 Other Or Procedures On Vessels Other Than Head And Neck
61 37790 Other Or Procedures On Vessels Other Than Head And Neck
61 37799 Other Or Procedures On Vessels Other Than Head And Neck
66 38100 Procedures On Spleen
66 38101 Procedures On Spleen
66 38102 Procedures On Spleen
66 38115 Procedures On Spleen
66 38120 Procedures On Spleen
66 38129 Procedures On Spleen
226 38200 Other Diagnostic Radiology And Related Techniques
67 38204 Other Therapeutic Procedures, Hemic And Lymphatic System
64 38205 Bone Marrow Transplant
64 38206 Bone Marrow Transplant
64 38207 Bone Marrow Transplant
64 38208 Bone Marrow Transplant
64 38209 Bone Marrow Transplant
64 38210 Bone Marrow Transplant
64 38211 Bone Marrow Transplant
64 38212 Bone Marrow Transplant
64 38213 Bone Marrow Transplant
64 38214 Bone Marrow Transplant
64 38215 Bone Marrow Transplant
65 38220 Bone Marrow Biopsy
65 38221 Bone Marrow Biopsy
65 38222 Bone Marrow Biopsy
67 38230 Other Therapeutic Procedures, Hemic And Lymphatic System
67 38232 Other Therapeutic Procedures, Hemic And Lymphatic System
64 38240 Bone Marrow Transplant
64 38241 Bone Marrow Transplant
64 38242 Bone Marrow Transplant
64 38243 Bone Marrow Transplant
67 38300 Other Therapeutic Procedures, Hemic And Lymphatic System
67 38305 Other Therapeutic Procedures, Hemic And Lymphatic System
67 38308 Other Therapeutic Procedures, Hemic And Lymphatic System
67 38380 Other Therapeutic Procedures, Hemic And Lymphatic System
67 38381 Other Therapeutic Procedures, Hemic And Lymphatic System
67 38382 Other Therapeutic Procedures, Hemic And Lymphatic System
67 38500 Other Therapeutic Procedures, Hemic And Lymphatic System
67 38505 Other Therapeutic Procedures, Hemic And Lymphatic System
67 38510 Other Therapeutic Procedures, Hemic And Lymphatic System
67 38520 Other Therapeutic Procedures, Hemic And Lymphatic System
67 38525 Other Therapeutic Procedures, Hemic And Lymphatic System
67 38530 Other Therapeutic Procedures, Hemic And Lymphatic System
67 38531 Other Therapeutic Procedures, Hemic And Lymphatic System
67 38542 Other Therapeutic Procedures, Hemic And Lymphatic System
67 38550 Other Therapeutic Procedures, Hemic And Lymphatic System
67 38555 Other Therapeutic Procedures, Hemic And Lymphatic System
67 38562 Other Therapeutic Procedures, Hemic And Lymphatic System
67 38564 Other Therapeutic Procedures, Hemic And Lymphatic System
67 38570 Other Therapeutic Procedures, Hemic And Lymphatic System
Blue Cross NC Proprietary and Confidential 43 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
67 38571 Other Therapeutic Procedures, Hemic And Lymphatic System
67 38572 Other Therapeutic Procedures, Hemic And Lymphatic System
67 38573 Other Therapeutic Procedures, Hemic And Lymphatic System
67 38589 Other Therapeutic Procedures, Hemic And Lymphatic System
67 38700 Other Therapeutic Procedures, Hemic And Lymphatic System
67 38720 Other Therapeutic Procedures, Hemic And Lymphatic System
67 38724 Other Therapeutic Procedures, Hemic And Lymphatic System
67 38740 Other Therapeutic Procedures, Hemic And Lymphatic System
67 38745 Other Therapeutic Procedures, Hemic And Lymphatic System
67 38746 Other Therapeutic Procedures, Hemic And Lymphatic System
67 38747 Other Therapeutic Procedures, Hemic And Lymphatic System
67 38760 Other Therapeutic Procedures, Hemic And Lymphatic System
67 38765 Other Therapeutic Procedures, Hemic And Lymphatic System
67 38770 Other Therapeutic Procedures, Hemic And Lymphatic System
67 38780 Other Therapeutic Procedures, Hemic And Lymphatic System
226 38790 Other Diagnostic Radiology And Related Techniques
226 38792 Other Diagnostic Radiology And Related Techniques
67 38794 Other Therapeutic Procedures, Hemic And Lymphatic System
67 38900 Other Therapeutic Procedures, Hemic And Lymphatic System
67 38999 Other Therapeutic Procedures, Hemic And Lymphatic System
42 39000 Other Or Therapeutic Procedures On Respiratory System
42 39010 Other Or Therapeutic Procedures On Respiratory System
42 39200 Other Or Therapeutic Procedures On Respiratory System
42 39220 Other Or Therapeutic Procedures On Respiratory System
40 39401 Other Diagnostic Procedures Of Respiratory Tract And Mediastinum
40 39402 Other Diagnostic Procedures Of Respiratory Tract And Mediastinum
42 39499 Other Or Therapeutic Procedures On Respiratory System
42 39501 Other Or Therapeutic Procedures On Respiratory System
86 39503 Other Hernia Repair
86 39540 Other Hernia Repair
86 39541 Other Hernia Repair
42 39545 Other Or Therapeutic Procedures On Respiratory System
42 39560 Other Or Therapeutic Procedures On Respiratory System
42 39561 Other Or Therapeutic Procedures On Respiratory System
42 39599 Other Or Therapeutic Procedures On Respiratory System
31 40490 Diagnostic Procedures On Nose, Mouth And Pharynx
33 40500 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 40510 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 40520 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 40525 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 40527 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 40530 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 40650 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 40652 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 40654 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 40700 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 40701 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 40702 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 40720 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 40761 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 40799 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 40800 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 40801 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
229 40804 Nonoperative Removal Of Foreign Body
229 40805 Nonoperative Removal Of Foreign Body
32 40806 Other Non-Or Therapeutic Procedures On Nose, Mouth And Pharynx
31 40808 Diagnostic Procedures On Nose, Mouth And Pharynx
33 40810 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 40812 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 40814 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 40816 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
172 40818 Skin Graft
32 40819 Other Non-Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 40820 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
32 40830 Other Non-Or Therapeutic Procedures On Nose, Mouth And Pharynx
32 40831 Other Non-Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 40840 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 40842 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 40843 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 40844 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 40845 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 40899 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 41000 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 41005 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
Blue Cross NC Proprietary and Confidential 44 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
33 41006 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 41007 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 41008 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 41009 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
32 41010 Other Non-Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 41015 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 41016 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 41017 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 41018 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
211 41019 Therapeutic Radiology
31 41100 Diagnostic Procedures On Nose, Mouth And Pharynx
31 41105 Diagnostic Procedures On Nose, Mouth And Pharynx
31 41108 Diagnostic Procedures On Nose, Mouth And Pharynx
33 41110 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 41112 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 41113 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 41114 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
32 41115 Other Non-Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 41116 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 41120 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 41130 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 41135 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 41140 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 41145 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 41150 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 41153 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 41155 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
32 41250 Other Non-Or Therapeutic Procedures On Nose, Mouth And Pharynx
32 41251 Other Non-Or Therapeutic Procedures On Nose, Mouth And Pharynx
32 41252 Other Non-Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 41510 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 41512 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 41520 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 41530 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 41599 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
29 41800 Oral And Dental Services
29 41805 Oral And Dental Services
29 41806 Oral And Dental Services
33 41820 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
29 41821 Oral And Dental Services
29 41822 Oral And Dental Services
29 41823 Oral And Dental Services
29 41825 Oral And Dental Services
29 41826 Oral And Dental Services
29 41827 Oral And Dental Services
29 41828 Oral And Dental Services
29 41830 Oral And Dental Services
29 41850 Oral And Dental Services
33 41870 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 41872 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
29 41874 Oral And Dental Services
29 41899 Oral And Dental Services
32 42000 Other Non-Or Therapeutic Procedures On Nose, Mouth And Pharynx
31 42100 Diagnostic Procedures On Nose, Mouth And Pharynx
33 42104 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 42106 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 42107 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 42120 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 42140 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 42145 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 42160 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 42180 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 42182 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 42200 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 42205 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 42210 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 42215 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 42220 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 42225 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 42226 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 42227 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 42235 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 42260 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 42280 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
Blue Cross NC Proprietary and Confidential 45 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
33 42281 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 42299 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 42300 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 42305 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 42310 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 42320 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 42330 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 42335 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 42340 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
31 42400 Diagnostic Procedures On Nose, Mouth And Pharynx
31 42405 Diagnostic Procedures On Nose, Mouth And Pharynx
33 42408 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 42409 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 42410 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 42415 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 42420 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 42425 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 42426 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 42440 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 42450 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 42500 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 42505 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 42507 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 42509 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 42510 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
226 42550 Other Diagnostic Radiology And Related Techniques
33 42600 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 42650 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 42660 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 42665 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 42699 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 42700 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 42720 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 42725 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
31 42800 Diagnostic Procedures On Nose, Mouth And Pharynx
31 42804 Diagnostic Procedures On Nose, Mouth And Pharynx
31 42806 Diagnostic Procedures On Nose, Mouth And Pharynx
33 42808 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
229 42809 Nonoperative Removal Of Foreign Body
33 42810 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 42815 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
30 42820 Tonsillectomy And/Or Adenoidectomy
30 42821 Tonsillectomy And/Or Adenoidectomy
30 42825 Tonsillectomy And/Or Adenoidectomy
30 42826 Tonsillectomy And/Or Adenoidectomy
30 42830 Tonsillectomy And/Or Adenoidectomy
30 42831 Tonsillectomy And/Or Adenoidectomy
30 42835 Tonsillectomy And/Or Adenoidectomy
30 42836 Tonsillectomy And/Or Adenoidectomy
33 42842 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 42844 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 42845 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
30 42860 Tonsillectomy And/Or Adenoidectomy
30 42870 Tonsillectomy And/Or Adenoidectomy
33 42890 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 42892 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 42894 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 42900 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 42950 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 42953 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 42955 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
32 42960 Other Non-Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 42961 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 42962 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
27 42970 Control Of Epistaxis
33 42971 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 42972 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
33 42999 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
94 43020 Other Or Upper GI Therapeutic Procedures
33 43030 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
94 43045 Other Or Upper GI Therapeutic Procedures
94 43100 Other Or Upper GI Therapeutic Procedures
94 43101 Other Or Upper GI Therapeutic Procedures
94 43107 Other Or Upper GI Therapeutic Procedures
Blue Cross NC Proprietary and Confidential 46 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
94 43108 Other Or Upper GI Therapeutic Procedures
94 43112 Other Or Upper GI Therapeutic Procedures
94 43113 Other Or Upper GI Therapeutic Procedures
94 43116 Other Or Upper GI Therapeutic Procedures
94 43117 Other Or Upper GI Therapeutic Procedures
94 43118 Other Or Upper GI Therapeutic Procedures
94 43121 Other Or Upper GI Therapeutic Procedures
94 43122 Other Or Upper GI Therapeutic Procedures
94 43123 Other Or Upper GI Therapeutic Procedures
94 43124 Other Or Upper GI Therapeutic Procedures
94 43130 Other Or Upper GI Therapeutic Procedures
94 43135 Other Or Upper GI Therapeutic Procedures
70 43180 Upper Gastrointestinal Endoscopy, Biopsy
70 43191 Upper Gastrointestinal Endoscopy, Biopsy
70 43192 Upper Gastrointestinal Endoscopy, Biopsy
70 43193 Upper Gastrointestinal Endoscopy, Biopsy
229 43194 Nonoperative Removal Of Foreign Body
69 43195 Esophageal Dilatation
69 43196 Esophageal Dilatation
70 43197 Upper Gastrointestinal Endoscopy, Biopsy
70 43198 Upper Gastrointestinal Endoscopy, Biopsy
70 43200 Upper Gastrointestinal Endoscopy, Biopsy
70 43201 Upper Gastrointestinal Endoscopy, Biopsy
70 43202 Upper Gastrointestinal Endoscopy, Biopsy
70 43204 Upper Gastrointestinal Endoscopy, Biopsy
70 43205 Upper Gastrointestinal Endoscopy, Biopsy
70 43206 Upper Gastrointestinal Endoscopy, Biopsy
70 43210 Upper Gastrointestinal Endoscopy, Biopsy
70 43211 Upper Gastrointestinal Endoscopy, Biopsy
70 43212 Upper Gastrointestinal Endoscopy, Biopsy
69 43213 Esophageal Dilatation
69 43214 Esophageal Dilatation
229 43215 Nonoperative Removal Of Foreign Body
93 43216 Other Non-Or Upper GI Therapeutic Procedures
70 43217 Upper Gastrointestinal Endoscopy, Biopsy
69 43220 Esophageal Dilatation
69 43226 Esophageal Dilatation
93 43227 Other Non-Or Upper GI Therapeutic Procedures
70 43229 Upper Gastrointestinal Endoscopy, Biopsy
70 43231 Upper Gastrointestinal Endoscopy, Biopsy
70 43232 Upper Gastrointestinal Endoscopy, Biopsy
69 43233 Esophageal Dilatation
70 43235 Upper Gastrointestinal Endoscopy, Biopsy
70 43236 Upper Gastrointestinal Endoscopy, Biopsy
70 43237 Upper Gastrointestinal Endoscopy, Biopsy
70 43238 Upper Gastrointestinal Endoscopy, Biopsy
70 43239 Upper Gastrointestinal Endoscopy, Biopsy
70 43240 Upper Gastrointestinal Endoscopy, Biopsy
70 43241 Upper Gastrointestinal Endoscopy, Biopsy
70 43242 Upper Gastrointestinal Endoscopy, Biopsy
68 43243 Injection Or Ligation Of Esophageal Varices
68 43244 Injection Or Ligation Of Esophageal Varices
93 43245 Other Non-Or Upper GI Therapeutic Procedures
71 43246 Gastrostomy, Temporary And Permanent
70 43247 Upper Gastrointestinal Endoscopy, Biopsy
69 43248 Esophageal Dilatation
69 43249 Esophageal Dilatation
70 43250 Upper Gastrointestinal Endoscopy, Biopsy
70 43251 Upper Gastrointestinal Endoscopy, Biopsy
70 43252 Upper Gastrointestinal Endoscopy, Biopsy
70 43253 Upper Gastrointestinal Endoscopy, Biopsy
70 43254 Upper Gastrointestinal Endoscopy, Biopsy
70 43255 Upper Gastrointestinal Endoscopy, Biopsy
70 43257 Upper Gastrointestinal Endoscopy, Biopsy
70 43259 Upper Gastrointestinal Endoscopy, Biopsy
82 43260 Endoscopic Retrograde Cannulation Of Pancreas (ERCP)
82 43261 Endoscopic Retrograde Cannulation Of Pancreas (ERCP)
82 43262 Endoscopic Retrograde Cannulation Of Pancreas (ERCP)
82 43263 Endoscopic Retrograde Cannulation Of Pancreas (ERCP)
82 43264 Endoscopic Retrograde Cannulation Of Pancreas (ERCP)
82 43265 Endoscopic Retrograde Cannulation Of Pancreas (ERCP)
70 43266 Upper Gastrointestinal Endoscopy, Biopsy
70 43270 Upper Gastrointestinal Endoscopy, Biopsy
82 43273 Endoscopic Retrograde Cannulation Of Pancreas (ERCP)
Blue Cross NC Proprietary and Confidential 47 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
82 43274 Endoscopic Retrograde Cannulation Of Pancreas (ERCP)
82 43275 Endoscopic Retrograde Cannulation Of Pancreas (ERCP)
82 43276 Endoscopic Retrograde Cannulation Of Pancreas (ERCP)
82 43277 Endoscopic Retrograde Cannulation Of Pancreas (ERCP)
82 43278 Endoscopic Retrograde Cannulation Of Pancreas (ERCP)
94 43279 Other Or Upper GI Therapeutic Procedures
94 43280 Other Or Upper GI Therapeutic Procedures
86 43281 Other Hernia Repair
86 43282 Other Hernia Repair
94 43283 Other Or Upper GI Therapeutic Procedures
94 43284 Other Or Upper GI Therapeutic Procedures
94 43285 Other Or Upper GI Therapeutic Procedures
94 43286 Other Or Upper GI Therapeutic Procedures
94 43287 Other Or Upper GI Therapeutic Procedures
94 43288 Other Or Upper GI Therapeutic Procedures
87 43289 Laparoscopy
94 43300 Other Or Upper GI Therapeutic Procedures
94 43305 Other Or Upper GI Therapeutic Procedures
94 43310 Other Or Upper GI Therapeutic Procedures
94 43312 Other Or Upper GI Therapeutic Procedures
94 43313 Other Or Upper GI Therapeutic Procedures
94 43314 Other Or Upper GI Therapeutic Procedures
94 43320 Other Or Upper GI Therapeutic Procedures
94 43325 Other Or Upper GI Therapeutic Procedures
94 43327 Other Or Upper GI Therapeutic Procedures
94 43328 Other Or Upper GI Therapeutic Procedures
94 43330 Other Or Upper GI Therapeutic Procedures
94 43331 Other Or Upper GI Therapeutic Procedures
86 43332 Other Hernia Repair
86 43333 Other Hernia Repair
86 43334 Other Hernia Repair
86 43335 Other Hernia Repair
86 43336 Other Hernia Repair
86 43337 Other Hernia Repair
94 43338 Other Or Upper GI Therapeutic Procedures
94 43340 Other Or Upper GI Therapeutic Procedures
94 43341 Other Or Upper GI Therapeutic Procedures
94 43351 Other Or Upper GI Therapeutic Procedures
94 43352 Other Or Upper GI Therapeutic Procedures
94 43360 Other Or Upper GI Therapeutic Procedures
94 43361 Other Or Upper GI Therapeutic Procedures
68 43400 Injection Or Ligation Of Esophageal Varices
94 43405 Other Or Upper GI Therapeutic Procedures
94 43410 Other Or Upper GI Therapeutic Procedures
94 43415 Other Or Upper GI Therapeutic Procedures
94 43420 Other Or Upper GI Therapeutic Procedures
94 43425 Other Or Upper GI Therapeutic Procedures
69 43450 Esophageal Dilatation
69 43453 Esophageal Dilatation
69 43460 Esophageal Dilatation
75 43496 Small Bowel Resection
94 43499 Other Or Upper GI Therapeutic Procedures
94 43500 Other Or Upper GI Therapeutic Procedures
94 43501 Other Or Upper GI Therapeutic Procedures
94 43502 Other Or Upper GI Therapeutic Procedures
69 43510 Esophageal Dilatation
94 43520 Other Or Upper GI Therapeutic Procedures
89 43605 Exploratory Laparotomy
94 43610 Other Or Upper GI Therapeutic Procedures
94 43611 Other Or Upper GI Therapeutic Procedures
74 43620 Gastrectomy, Partial And Total
74 43621 Gastrectomy, Partial And Total
74 43622 Gastrectomy, Partial And Total
74 43631 Gastrectomy, Partial And Total
74 43632 Gastrectomy, Partial And Total
74 43633 Gastrectomy, Partial And Total
74 43634 Gastrectomy, Partial And Total
94 43635 Other Or Upper GI Therapeutic Procedures
94 43640 Other Or Upper GI Therapeutic Procedures
94 43641 Other Or Upper GI Therapeutic Procedures
244 43644 Gastric Bypass And Volume Reduction
244 43645 Gastric Bypass And Volume Reduction
94 43647 Other Or Upper GI Therapeutic Procedures
94 43648 Other Or Upper GI Therapeutic Procedures
Blue Cross NC Proprietary and Confidential 48 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
94 43651 Other Or Upper GI Therapeutic Procedures
94 43652 Other Or Upper GI Therapeutic Procedures
71 43653 Gastrostomy, Temporary And Permanent
87 43659 Laparoscopy
221 43752 Nasogastric Tube
221 43753 Nasogastric Tube
221 43754 Nasogastric Tube
221 43755 Nasogastric Tube
221 43756 Nasogastric Tube
221 43757 Nasogastric Tube
94 43761 Other Or Upper GI Therapeutic Procedures
98 43762 Other Non-Or Gastrointestinal Therapeutic Procedures
98 43763 Other Non-Or Gastrointestinal Therapeutic Procedures
244 43770 Gastric Bypass And Volume Reduction
244 43771 Gastric Bypass And Volume Reduction
244 43772 Gastric Bypass And Volume Reduction
244 43773 Gastric Bypass And Volume Reduction
244 43774 Gastric Bypass And Volume Reduction
244 43775 Gastric Bypass And Volume Reduction
94 43800 Other Or Upper GI Therapeutic Procedures
94 43810 Other Or Upper GI Therapeutic Procedures
94 43820 Other Or Upper GI Therapeutic Procedures
94 43825 Other Or Upper GI Therapeutic Procedures
71 43830 Gastrostomy, Temporary And Permanent
71 43831 Gastrostomy, Temporary And Permanent
71 43832 Gastrostomy, Temporary And Permanent
94 43840 Other Or Upper GI Therapeutic Procedures
244 43842 Gastric Bypass And Volume Reduction
244 43843 Gastric Bypass And Volume Reduction
244 43845 Gastric Bypass And Volume Reduction
244 43846 Gastric Bypass And Volume Reduction
244 43847 Gastric Bypass And Volume Reduction
244 43848 Gastric Bypass And Volume Reduction
94 43850 Other Or Upper GI Therapeutic Procedures
94 43855 Other Or Upper GI Therapeutic Procedures
94 43860 Other Or Upper GI Therapeutic Procedures
94 43865 Other Or Upper GI Therapeutic Procedures
94 43870 Other Or Upper GI Therapeutic Procedures
94 43880 Other Or Upper GI Therapeutic Procedures
94 43881 Other Or Upper GI Therapeutic Procedures
94 43882 Other Or Upper GI Therapeutic Procedures
244 43886 Gastric Bypass And Volume Reduction
244 43887 Gastric Bypass And Volume Reduction
244 43888 Gastric Bypass And Volume Reduction
94 43999 Other Or Upper GI Therapeutic Procedures
90 44005 Excision, Lysis Peritoneal Adhesions
92 44010 Other Bowel Diagnostic Procedures
73 44015 Ileostomy And Other Enterostomy
92 44020 Other Bowel Diagnostic Procedures
96 44021 Other Or Lower GI Therapeutic Procedures
92 44025 Other Bowel Diagnostic Procedures
96 44050 Other Or Lower GI Therapeutic Procedures
96 44055 Other Or Lower GI Therapeutic Procedures
92 44100 Other Bowel Diagnostic Procedures
79 44110 Local Excision Of Large Intestine Lesion (Not Endoscopic)
79 44111 Local Excision Of Large Intestine Lesion (Not Endoscopic)
75 44120 Small Bowel Resection
75 44121 Small Bowel Resection
75 44125 Small Bowel Resection
75 44126 Small Bowel Resection
75 44127 Small Bowel Resection
75 44128 Small Bowel Resection
73 44130 Ileostomy And Other Enterostomy
75 44132 Small Bowel Resection
75 44133 Small Bowel Resection
176 44135 Other Organ Transplantation
176 44136 Other Organ Transplantation
99 44137 Other Or Gastrointestinal Therapeutic Procedures
78 44139 Colorectal Resection
78 44140 Colorectal Resection
78 44141 Colorectal Resection
78 44143 Colorectal Resection
78 44144 Colorectal Resection
78 44145 Colorectal Resection
Blue Cross NC Proprietary and Confidential 49 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
78 44146 Colorectal Resection
78 44147 Colorectal Resection
78 44150 Colorectal Resection
78 44151 Colorectal Resection
78 44155 Colorectal Resection
78 44156 Colorectal Resection
78 44157 Colorectal Resection
78 44158 Colorectal Resection
78 44160 Colorectal Resection
96 44180 Other Or Lower GI Therapeutic Procedures
73 44186 Ileostomy And Other Enterostomy
73 44187 Ileostomy And Other Enterostomy
72 44188 Colostomy, Temporary And Permanent
75 44202 Small Bowel Resection
75 44203 Small Bowel Resection
78 44204 Colorectal Resection
78 44205 Colorectal Resection
78 44206 Colorectal Resection
78 44207 Colorectal Resection
78 44208 Colorectal Resection
78 44210 Colorectal Resection
78 44211 Colorectal Resection
78 44212 Colorectal Resection
78 44213 Colorectal Resection
96 44227 Other Or Lower GI Therapeutic Procedures
87 44238 Laparoscopy
73 44300 Ileostomy And Other Enterostomy
73 44310 Ileostomy And Other Enterostomy
73 44312 Ileostomy And Other Enterostomy
73 44314 Ileostomy And Other Enterostomy
73 44316 Ileostomy And Other Enterostomy
72 44320 Colostomy, Temporary And Permanent
72 44322 Colostomy, Temporary And Permanent
72 44340 Colostomy, Temporary And Permanent
72 44345 Colostomy, Temporary And Permanent
86 44346 Other Hernia Repair
70 44360 Upper Gastrointestinal Endoscopy, Biopsy
70 44361 Upper Gastrointestinal Endoscopy, Biopsy
229 44363 Nonoperative Removal Of Foreign Body
99 44364 Other Or Gastrointestinal Therapeutic Procedures
99 44365 Other Or Gastrointestinal Therapeutic Procedures
99 44366 Other Or Gastrointestinal Therapeutic Procedures
99 44369 Other Or Gastrointestinal Therapeutic Procedures
96 44370 Other Or Lower GI Therapeutic Procedures
96 44372 Other Or Lower GI Therapeutic Procedures
71 44373 Gastrostomy, Temporary And Permanent
70 44376 Upper Gastrointestinal Endoscopy, Biopsy
70 44377 Upper Gastrointestinal Endoscopy, Biopsy
93 44378 Other Non-Or Upper GI Therapeutic Procedures
70 44379 Upper Gastrointestinal Endoscopy, Biopsy
70 44380 Upper Gastrointestinal Endoscopy, Biopsy
70 44381 Upper Gastrointestinal Endoscopy, Biopsy
70 44382 Upper Gastrointestinal Endoscopy, Biopsy
70 44384 Upper Gastrointestinal Endoscopy, Biopsy
70 44385 Upper Gastrointestinal Endoscopy, Biopsy
70 44386 Upper Gastrointestinal Endoscopy, Biopsy
76 44388 Colonoscopy And Biopsy
76 44389 Colonoscopy And Biopsy
229 44390 Nonoperative Removal Of Foreign Body
76 44391 Colonoscopy And Biopsy
76 44392 Colonoscopy And Biopsy
76 44394 Colonoscopy And Biopsy
76 44401 Colonoscopy And Biopsy
76 44402 Colonoscopy And Biopsy
76 44403 Colonoscopy And Biopsy
76 44404 Colonoscopy And Biopsy
76 44405 Colonoscopy And Biopsy
76 44406 Colonoscopy And Biopsy
76 44407 Colonoscopy And Biopsy
76 44408 Colonoscopy And Biopsy
98 44500 Other Non-Or Gastrointestinal Therapeutic Procedures
96 44602 Other Or Lower GI Therapeutic Procedures
96 44603 Other Or Lower GI Therapeutic Procedures
96 44604 Other Or Lower GI Therapeutic Procedures
Blue Cross NC Proprietary and Confidential 50 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
72 44605 Colostomy, Temporary And Permanent
94 44615 Other Or Lower GI Therapeutic Procedures
96 44620 Other Or Lower GI Therapeutic Procedures
96 44625 Other Or Lower GI Therapeutic Procedures
96 44626 Other Or Lower GI Therapeutic Procedures
96 44640 Other Or Lower GI Therapeutic Procedures
96 44650 Other Or Lower GI Therapeutic Procedures
96 44660 Other Or Lower GI Therapeutic Procedures
75 44661 Small Bowel Resection
96 44680 Other Or Lower GI Therapeutic Procedures
96 44700 Other Or Lower GI Therapeutic Procedures
96 44701 Other Or Lower GI Therapeutic Procedures
95 44705 Other Non-Or Lower GI Therapeutic Procedures
176 44715 Other Organ Transplantation
176 44720 Other Organ Transplantation
176 44721 Other Organ Transplantation
96 44799 Other Or Lower GI Therapeutic Procedures
96 44800 Other Or Lower GI Therapeutic Procedures
96 44820 Other Or Lower GI Therapeutic Procedures
96 44850 Other Or Lower GI Therapeutic Procedures
96 44899 Other Or Lower GI Therapeutic Procedures
96 44900 Other Or Lower GI Therapeutic Procedures
80 44950 Appendectomy
80 44955 Appendectomy
80 44960 Appendectomy
80 44970 Appendectomy
80 44979 Appendectomy
96 45000 Other Or Lower GI Therapeutic Procedures
96 45005 Other Or Lower GI Therapeutic Procedures
96 45020 Other Or Lower GI Therapeutic Procedures
77 45100 Proctoscopy And Anorectal Biopsy
96 45108 Other Or Lower GI Therapeutic Procedures
78 45110 Colorectal Resection
78 45111 Colorectal Resection
78 45112 Colorectal Resection
78 45113 Colorectal Resection
78 45114 Colorectal Resection
78 45116 Colorectal Resection
78 45119 Colorectal Resection
78 45120 Colorectal Resection
78 45121 Colorectal Resection
78 45123 Colorectal Resection
78 45126 Colorectal Resection
78 45130 Colorectal Resection
78 45135 Colorectal Resection
78 45136 Colorectal Resection
96 45150 Other Or Lower GI Therapeutic Procedures
78 45160 Colorectal Resection
78 45171 Colorectal Resection
78 45172 Colorectal Resection
95 45190 Other Non-Or Lower GI Therapeutic Procedures
77 45300 Proctoscopy And Anorectal Biopsy
77 45303 Proctoscopy And Anorectal Biopsy
77 45305 Proctoscopy And Anorectal Biopsy
229 45307 Nonoperative Removal Of Foreign Body
77 45308 Proctoscopy And Anorectal Biopsy
77 45309 Proctoscopy And Anorectal Biopsy
77 45315 Proctoscopy And Anorectal Biopsy
77 45317 Proctoscopy And Anorectal Biopsy
77 45320 Proctoscopy And Anorectal Biopsy
77 45321 Proctoscopy And Anorectal Biopsy
77 45327 Proctoscopy And Anorectal Biopsy
77 45330 Proctoscopy And Anorectal Biopsy
77 45331 Proctoscopy And Anorectal Biopsy
229 45332 Nonoperative Removal Of Foreign Body
77 45333 Proctoscopy And Anorectal Biopsy
77 45334 Proctoscopy And Anorectal Biopsy
77 45335 Proctoscopy And Anorectal Biopsy
77 45337 Proctoscopy And Anorectal Biopsy
77 45338 Proctoscopy And Anorectal Biopsy
77 45340 Proctoscopy And Anorectal Biopsy
77 45341 Proctoscopy And Anorectal Biopsy
77 45342 Proctoscopy And Anorectal Biopsy
77 45346 Proctoscopy And Anorectal Biopsy
Blue Cross NC Proprietary and Confidential 51 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
77 45347 Proctoscopy And Anorectal Biopsy
77 45349 Proctoscopy And Anorectal Biopsy
77 45350 Proctoscopy And Anorectal Biopsy
76 45378 Colonoscopy And Biopsy
229 45379 Nonoperative Removal Of Foreign Body
76 45380 Colonoscopy And Biopsy
76 45381 Colonoscopy And Biopsy
76 45382 Colonoscopy And Biopsy
76 45384 Colonoscopy And Biopsy
76 45385 Colonoscopy And Biopsy
76 45386 Colonoscopy And Biopsy
76 45388 Colonoscopy And Biopsy
76 45389 Colonoscopy And Biopsy
76 45390 Colonoscopy And Biopsy
76 45391 Colonoscopy And Biopsy
76 45392 Colonoscopy And Biopsy
76 45393 Colonoscopy And Biopsy
78 45395 Colorectal Resection
78 45397 Colorectal Resection
76 45398 Colonoscopy And Biopsy
96 45399 Other Or Lower GI Therapeutic Procedures
96 45400 Other Or Lower GI Therapeutic Procedures
78 45402 Colorectal Resection
87 45499 Laparoscopy
76 45500 Colonoscopy And Biopsy
76 45505 Colonoscopy And Biopsy
98 45520 Other Non-Or Gastrointestinal Therapeutic Procedures
96 45540 Other Or Lower GI Therapeutic Procedures
96 45541 Other Or Lower GI Therapeutic Procedures
78 45550 Colorectal Resection
129 45560 Repair Of Cystocele And Rectocele, Obliteration Of Vaginal Vault
96 45562 Other Or Lower GI Therapeutic Procedures
72 45563 Colostomy, Temporary And Permanent
96 45800 Other Or Lower GI Therapeutic Procedures
72 45805 Colostomy, Temporary And Permanent
96 45820 Other Or Lower GI Therapeutic Procedures
72 45825 Colostomy, Temporary And Permanent
96 45900 Other Or Lower GI Therapeutic Procedures
96 45905 Other Or Lower GI Therapeutic Procedures
96 45910 Other Or Lower GI Therapeutic Procedures
96 45915 Other Or Lower GI Therapeutic Procedures
97 45990 Other Gastrointestinal Diagnostic Procedures
96 45999 Other Or Lower GI Therapeutic Procedures
96 46020 Other Or Lower GI Therapeutic Procedures
96 46030 Other Or Lower GI Therapeutic Procedures
96 46040 Other Or Lower GI Therapeutic Procedures
96 46045 Other Or Lower GI Therapeutic Procedures
96 46050 Other Or Lower GI Therapeutic Procedures
96 46060 Other Or Lower GI Therapeutic Procedures
96 46070 Other Or Lower GI Therapeutic Procedures
96 46080 Other Or Lower GI Therapeutic Procedures
81 46083 Hemorrhoid Procedures
96 46200 Other Or Lower GI Therapeutic Procedures
95 46220 Other Non-Or Lower GI Therapeutic Procedures
81 46221 Hemorrhoid Procedures
81 46230 Hemorrhoid Procedures
81 46250 Hemorrhoid Procedures
81 46255 Hemorrhoid Procedures
81 46257 Hemorrhoid Procedures
81 46258 Hemorrhoid Procedures
81 46260 Hemorrhoid Procedures
81 46261 Hemorrhoid Procedures
81 46262 Hemorrhoid Procedures
96 46270 Other Or Lower GI Therapeutic Procedures
96 46275 Other Or Lower GI Therapeutic Procedures
96 46280 Other Or Lower GI Therapeutic Procedures
96 46285 Other Or Lower GI Therapeutic Procedures
96 46288 Other Or Lower GI Therapeutic Procedures
81 46320 Hemorrhoid Procedures
81 46500 Hemorrhoid Procedures
96 46505 Other Or Lower GI Therapeutic Procedures
77 46600 Proctoscopy And Anorectal Biopsy
77 46601 Proctoscopy And Anorectal Biopsy
77 46604 Proctoscopy And Anorectal Biopsy
Blue Cross NC Proprietary and Confidential 52 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
77 46606 Proctoscopy And Anorectal Biopsy
77 46607 Proctoscopy And Anorectal Biopsy
229 46608 Nonoperative Removal Of Foreign Body
77 46610 Proctoscopy And Anorectal Biopsy
77 46611 Proctoscopy And Anorectal Biopsy
77 46612 Proctoscopy And Anorectal Biopsy
77 46614 Proctoscopy And Anorectal Biopsy
77 46615 Proctoscopy And Anorectal Biopsy
96 46700 Other Or Lower GI Therapeutic Procedures
96 46705 Other Or Lower GI Therapeutic Procedures
96 46706 Other Or Lower GI Therapeutic Procedures
96 46707 Other Or Lower GI Therapeutic Procedures
96 46710 Other Or Lower GI Therapeutic Procedures
96 46712 Other Or Lower GI Therapeutic Procedures
96 46715 Other Or Lower GI Therapeutic Procedures
96 46716 Other Or Lower GI Therapeutic Procedures
96 46730 Other Or Lower GI Therapeutic Procedures
96 46735 Other Or Lower GI Therapeutic Procedures
96 46740 Other Or Lower GI Therapeutic Procedures
96 46742 Other Or Lower GI Therapeutic Procedures
132 46744 Other Or Therapeutic Procedures, Female Organs
132 46746 Other Or Therapeutic Procedures, Female Organs
132 46748 Other Or Therapeutic Procedures, Female Organs
96 46750 Other Or Lower GI Therapeutic Procedures
96 46751 Other Or Lower GI Therapeutic Procedures
96 46753 Other Or Lower GI Therapeutic Procedures
96 46754 Other Or Lower GI Therapeutic Procedures
96 46760 Other Or Lower GI Therapeutic Procedures
96 46761 Other Or Lower GI Therapeutic Procedures
95 46900 Other Non-Or Lower GI Therapeutic Procedures
95 46910 Other Non-Or Lower GI Therapeutic Procedures
95 46916 Other Non-Or Lower GI Therapeutic Procedures
95 46917 Other Non-Or Lower GI Therapeutic Procedures
95 46922 Other Non-Or Lower GI Therapeutic Procedures
95 46924 Other Non-Or Lower GI Therapeutic Procedures
81 46930 Hemorrhoid Procedures
95 46940 Other Non-Or Lower GI Therapeutic Procedures
95 46942 Other Non-Or Lower GI Therapeutic Procedures
81 46945 Hemorrhoid Procedures
81 46946 Hemorrhoid Procedures
81 46947 Hemorrhoid Procedures
81 46948 Hemorrhoid Procedures
96 46999 Other Or Lower GI Therapeutic Procedures
83 47000 Biopsy Of Liver
83 47001 Biopsy Of Liver
99 47010 Other Or Gastrointestinal Therapeutic Procedures
99 47015 Other Or Gastrointestinal Therapeutic Procedures
83 47100 Biopsy Of Liver
99 47120 Other Or Gastrointestinal Therapeutic Procedures
99 47122 Other Or Gastrointestinal Therapeutic Procedures
99 47125 Other Or Gastrointestinal Therapeutic Procedures
99 47130 Other Or Gastrointestinal Therapeutic Procedures
99 47133 Other Or Gastrointestinal Therapeutic Procedures
176 47135 Other Organ Transplantation
176 47140 Other Organ Transplantation
176 47141 Other Organ Transplantation
176 47142 Other Organ Transplantation
176 47143 Other Organ Transplantation
176 47144 Other Organ Transplantation
176 47145 Other Organ Transplantation
176 47146 Other Organ Transplantation
176 47147 Other Organ Transplantation
99 47300 Other Or Gastrointestinal Therapeutic Procedures
99 47350 Other Or Gastrointestinal Therapeutic Procedures
99 47360 Other Or Gastrointestinal Therapeutic Procedures
99 47361 Other Or Gastrointestinal Therapeutic Procedures
99 47362 Other Or Gastrointestinal Therapeutic Procedures
99 47370 Other Or Gastrointestinal Therapeutic Procedures
99 47371 Other Or Gastrointestinal Therapeutic Procedures
99 47379 Other Or Gastrointestinal Therapeutic Procedures
99 47380 Other Or Gastrointestinal Therapeutic Procedures
99 47381 Other Or Gastrointestinal Therapeutic Procedures
99 47382 Other Or Gastrointestinal Therapeutic Procedures
99 47383 Other Or Gastrointestinal Therapeutic Procedures
Blue Cross NC Proprietary and Confidential 53 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
99 47399 Other Or Gastrointestinal Therapeutic Procedures
84 47400 Cholecystectomy And Common Duct Exploration
84 47420 Cholecystectomy And Common Duct Exploration
84 47425 Cholecystectomy And Common Duct Exploration
84 47460 Cholecystectomy And Common Duct Exploration
99 47480 Other Or Gastrointestinal Therapeutic Procedures
99 47490 Other Or Gastrointestinal Therapeutic Procedures
226 47531 Other Diagnostic Radiology And Related Techniques
226 47532 Other Diagnostic Radiology And Related Techniques
99 47533 Other Or Gastrointestinal Therapeutic Procedures
99 47534 Other Or Gastrointestinal Therapeutic Procedures
99 47535 Other Or Gastrointestinal Therapeutic Procedures
98 47536 Other Non-Or Gastrointestinal Therapeutic Procedures
98 47537 Other Non-Or Gastrointestinal Therapeutic Procedures
99 47538 Other Or Gastrointestinal Therapeutic Procedures
99 47539 Other Or Gastrointestinal Therapeutic Procedures
99 47540 Other Or Gastrointestinal Therapeutic Procedures
99 47541 Other Or Gastrointestinal Therapeutic Procedures
99 47542 Other Or Gastrointestinal Therapeutic Procedures
97 47543 Other Gastrointestinal Diagnostic Procedures
99 47544 Other Or Gastrointestinal Therapeutic Procedures
84 47550 Cholecystectomy And Common Duct Exploration
97 47552 Other Gastrointestinal Diagnostic Procedures
97 47553 Other Gastrointestinal Diagnostic Procedures
99 47554 Other Or Gastrointestinal Therapeutic Procedures
99 47555 Other Or Gastrointestinal Therapeutic Procedures
99 47556 Other Or Gastrointestinal Therapeutic Procedures
84 47562 Cholecystectomy And Common Duct Exploration
84 47563 Cholecystectomy And Common Duct Exploration
84 47564 Cholecystectomy And Common Duct Exploration
99 47570 Other Or Gastrointestinal Therapeutic Procedures
87 47579 Laparoscopy
84 47600 Cholecystectomy And Common Duct Exploration
84 47605 Cholecystectomy And Common Duct Exploration
84 47610 Cholecystectomy And Common Duct Exploration
84 47612 Cholecystectomy And Common Duct Exploration
84 47620 Cholecystectomy And Common Duct Exploration
97 47700 Other Gastrointestinal Diagnostic Procedures
99 47701 Other Or Gastrointestinal Therapeutic Procedures
99 47711 Other Or Gastrointestinal Therapeutic Procedures
99 47712 Other Or Gastrointestinal Therapeutic Procedures
99 47715 Other Or Gastrointestinal Therapeutic Procedures
99 47720 Other Or Gastrointestinal Therapeutic Procedures
99 47721 Other Or Gastrointestinal Therapeutic Procedures
99 47740 Other Or Gastrointestinal Therapeutic Procedures
99 47741 Other Or Gastrointestinal Therapeutic Procedures
99 47760 Other Or Gastrointestinal Therapeutic Procedures
99 47765 Other Or Gastrointestinal Therapeutic Procedures
99 47780 Other Or Gastrointestinal Therapeutic Procedures
99 47785 Other Or Gastrointestinal Therapeutic Procedures
99 47800 Other Or Gastrointestinal Therapeutic Procedures
99 47801 Other Or Gastrointestinal Therapeutic Procedures
73 47802 Ileostomy And Other Enterostomy
99 47900 Other Or Gastrointestinal Therapeutic Procedures
99 47999 Other Or Gastrointestinal Therapeutic Procedures
99 48000 Other Or Gastrointestinal Therapeutic Procedures
73 48001 Ileostomy And Other Enterostomy
99 48020 Other Or Gastrointestinal Therapeutic Procedures
97 48100 Other Gastrointestinal Diagnostic Procedures
97 48102 Other Gastrointestinal Diagnostic Procedures
99 48105 Other Or Gastrointestinal Therapeutic Procedures
99 48120 Other Or Gastrointestinal Therapeutic Procedures
99 48140 Other Or Gastrointestinal Therapeutic Procedures
99 48145 Other Or Gastrointestinal Therapeutic Procedures
99 48146 Other Or Gastrointestinal Therapeutic Procedures
99 48148 Other Or Gastrointestinal Therapeutic Procedures
73 48150 Ileostomy And Other Enterostomy
73 48152 Ileostomy And Other Enterostomy
73 48153 Ileostomy And Other Enterostomy
73 48154 Ileostomy And Other Enterostomy
99 48155 Other Or Gastrointestinal Therapeutic Procedures
176 48160 Other Organ Transplantation
97 48400 Other Gastrointestinal Diagnostic Procedures
99 48500 Other Or Gastrointestinal Therapeutic Procedures
Blue Cross NC Proprietary and Confidential 54 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
99 48510 Other Or Gastrointestinal Therapeutic Procedures
99 48520 Other Or Gastrointestinal Therapeutic Procedures
99 48540 Other Or Gastrointestinal Therapeutic Procedures
99 48545 Other Or Gastrointestinal Therapeutic Procedures
99 48547 Other Or Gastrointestinal Therapeutic Procedures
99 48548 Other Or Gastrointestinal Therapeutic Procedures
99 48550 Other Or Gastrointestinal Therapeutic Procedures
176 48551 Other Organ Transplantation
176 48552 Other Organ Transplantation
176 48554 Other Organ Transplantation
99 48556 Other Or Gastrointestinal Therapeutic Procedures
99 48999 Other Or Gastrointestinal Therapeutic Procedures
89 49000 Exploratory Laparotomy
89 49002 Exploratory Laparotomy
89 49010 Exploratory Laparotomy
89 49013 Exploratory Laparotomy
89 49014 Exploratory Laparotomy
99 49020 Other Or Gastrointestinal Therapeutic Procedures
99 49040 Other Or Gastrointestinal Therapeutic Procedures
99 49060 Other Or Gastrointestinal Therapeutic Procedures
67 49062 Other Therapeutic Procedures, Hemic And Lymphatic System
88 49082 Abdominal Paracentesis
88 49083 Abdominal Paracentesis
88 49084 Abdominal Paracentesis
97 49180 Other Gastrointestinal Diagnostic Procedures
99 49185 Other Or Gastrointestinal Therapeutic Procedures
99 49203 Other Or Gastrointestinal Therapeutic Procedures
99 49204 Other Or Gastrointestinal Therapeutic Procedures
99 49205 Other Or Gastrointestinal Therapeutic Procedures
99 49215 Other Or Gastrointestinal Therapeutic Procedures
89 49220 Exploratory Laparotomy
99 49250 Other Or Gastrointestinal Therapeutic Procedures
99 49255 Other Or Gastrointestinal Therapeutic Procedures
87 49320 Laparoscopy
87 49321 Laparoscopy
87 49322 Laparoscopy
87 49323 Laparoscopy
87 49324 Laparoscopy
87 49325 Laparoscopy
87 49326 Laparoscopy
87 49327 Laparoscopy
87 49329 Laparoscopy
97 49400 Other Gastrointestinal Diagnostic Procedures
99 49402 Other Or Gastrointestinal Therapeutic Procedures
99 49405 Other Or Gastrointestinal Therapeutic Procedures
99 49406 Other Or Gastrointestinal Therapeutic Procedures
99 49407 Other Or Gastrointestinal Therapeutic Procedures
98 49411 Other Non-Or Gastrointestinal Therapeutic Procedures
99 49412 Other Or Gastrointestinal Therapeutic Procedures
99 49418 Other Or Gastrointestinal Therapeutic Procedures
99 49419 Other Or Gastrointestinal Therapeutic Procedures
99 49421 Other Or Gastrointestinal Therapeutic Procedures
99 49422 Other Or Gastrointestinal Therapeutic Procedures
99 49423 Other Or Gastrointestinal Therapeutic Procedures
97 49424 Other Gastrointestinal Diagnostic Procedures
99 49425 Other Or Gastrointestinal Therapeutic Procedures
99 49426 Other Or Gastrointestinal Therapeutic Procedures
97 49427 Other Gastrointestinal Diagnostic Procedures
99 49428 Other Or Gastrointestinal Therapeutic Procedures
99 49429 Other Or Gastrointestinal Therapeutic Procedures
99 49435 Other Or Gastrointestinal Therapeutic Procedures
99 49436 Other Or Gastrointestinal Therapeutic Procedures
71 49440 Gastrostomy, Temporary And Permanent
73 49441 Ileostomy And Other Enterostomy
73 49442 Ileostomy And Other Enterostomy
73 49446 Ileostomy And Other Enterostomy
71 49450 Gastrostomy, Temporary And Permanent
73 49451 Ileostomy And Other Enterostomy
71 49452 Gastrostomy, Temporary And Permanent
99 49460 Other Or Gastrointestinal Therapeutic Procedures
226 49465 Other Diagnostic Radiology And Related Techniques
85 49491 Inguinal And Femoral Hernia Repair
85 49492 Inguinal And Femoral Hernia Repair
85 49495 Inguinal And Femoral Hernia Repair
Blue Cross NC Proprietary and Confidential 55 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
85 49496 Inguinal And Femoral Hernia Repair
85 49500 Inguinal And Femoral Hernia Repair
85 49501 Inguinal And Femoral Hernia Repair
85 49505 Inguinal And Femoral Hernia Repair
85 49507 Inguinal And Femoral Hernia Repair
85 49520 Inguinal And Femoral Hernia Repair
85 49521 Inguinal And Femoral Hernia Repair
85 49525 Inguinal And Femoral Hernia Repair
86 49540 Other Hernia Repair
85 49550 Inguinal And Femoral Hernia Repair
85 49553 Inguinal And Femoral Hernia Repair
85 49555 Inguinal And Femoral Hernia Repair
85 49557 Inguinal And Femoral Hernia Repair
86 49560 Other Hernia Repair
86 49561 Other Hernia Repair
86 49565 Other Hernia Repair
86 49566 Other Hernia Repair
86 49568 Other Hernia Repair
86 49570 Other Hernia Repair
86 49572 Other Hernia Repair
86 49580 Other Hernia Repair
86 49582 Other Hernia Repair
86 49585 Other Hernia Repair
86 49587 Other Hernia Repair
86 49590 Other Hernia Repair
86 49600 Other Hernia Repair
86 49605 Other Hernia Repair
86 49606 Other Hernia Repair
86 49610 Other Hernia Repair
86 49611 Other Hernia Repair
85 49650 Inguinal And Femoral Hernia Repair
85 49651 Inguinal And Femoral Hernia Repair
86 49652 Other Hernia Repair
86 49653 Other Hernia Repair
86 49654 Other Hernia Repair
86 49655 Other Hernia Repair
86 49656 Other Hernia Repair
86 49657 Other Hernia Repair
86 49659 Other Hernia Repair
99 49900 Other Or Gastrointestinal Therapeutic Procedures
99 49904 Other Or Gastrointestinal Therapeutic Procedures
99 49905 Other Or Gastrointestinal Therapeutic Procedures
99 49906 Other Or Gastrointestinal Therapeutic Procedures
99 49999 Other Or Gastrointestinal Therapeutic Procedures
103 50010 Nephrotomy And Nephrostomy
103 50020 Nephrotomy And Nephrostomy
103 50040 Nephrotomy And Nephrostomy
103 50045 Nephrotomy And Nephrostomy
103 50060 Nephrotomy And Nephrostomy
103 50065 Nephrotomy And Nephrostomy
103 50070 Nephrotomy And Nephrostomy
103 50075 Nephrotomy And Nephrostomy
103 50080 Nephrotomy And Nephrostomy
103 50081 Nephrotomy And Nephrostomy
61 50100 Other Or Procedures On Vessels Other Than Head And Neck
103 50120 Nephrotomy And Nephrostomy
103 50125 Nephrotomy And Nephrostomy
103 50130 Nephrotomy And Nephrostomy
103 50135 Nephrotomy And Nephrostomy
110 50200 Other Diagnostic Procedures Of Urinary Tract
110 50205 Other Diagnostic Procedures Of Urinary Tract
104 50220 Nephrectomy, Partial Or Complete
104 50225 Nephrectomy, Partial Or Complete
104 50230 Nephrectomy, Partial Or Complete
104 50234 Nephrectomy, Partial Or Complete
104 50236 Nephrectomy, Partial Or Complete
104 50240 Nephrectomy, Partial Or Complete
112 50250 Other Or Therapeutic Procedures Of Urinary Tract
112 50280 Other Or Therapeutic Procedures Of Urinary Tract
112 50290 Other Or Therapeutic Procedures Of Urinary Tract
104 50300 Nephrectomy, Partial Or Complete
104 50320 Nephrectomy, Partial Or Complete
104 50323 Nephrectomy, Partial Or Complete
104 50325 Nephrectomy, Partial Or Complete
Blue Cross NC Proprietary and Confidential 56 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
104 50327 Nephrectomy, Partial Or Complete
104 50328 Nephrectomy, Partial Or Complete
104 50329 Nephrectomy, Partial Or Complete
104 50340 Nephrectomy, Partial Or Complete
105 50360 Kidney Transplant
105 50365 Kidney Transplant
104 50370 Nephrectomy, Partial Or Complete
105 50380 Kidney Transplant
111 50382 Other Non-Or Therapeutic Procedures Of Urinary Tract
111 50384 Other Non-Or Therapeutic Procedures Of Urinary Tract
111 50385 Other Non-Or Therapeutic Procedures Of Urinary Tract
111 50386 Other Non-Or Therapeutic Procedures Of Urinary Tract
111 50387 Other Non-Or Therapeutic Procedures Of Urinary Tract
111 50389 Other Non-Or Therapeutic Procedures Of Urinary Tract
111 50390 Other Non-Or Therapeutic Procedures Of Urinary Tract
112 50391 Other Or Therapeutic Procedures Of Urinary Tract
200 50396 Nonoperative Urinary System Measurements
112 50400 Other Or Therapeutic Procedures Of Urinary Tract
112 50405 Other Or Therapeutic Procedures Of Urinary Tract
226 50430 Other Diagnostic Radiology And Related Techniques
226 50431 Other Diagnostic Radiology And Related Techniques
103 50432 Nephrotomy And Nephrostomy
103 50433 Nephrotomy And Nephrostomy
103 50434 Nephrotomy And Nephrostomy
103 50435 Nephrotomy And Nephrostomy
111 50436 Other Non-Or Therapeutic Procedures Of Urinary Tract
111 50437 Other Non-Or Therapeutic Procedures Of Urinary Tract
112 50500 Other Or Therapeutic Procedures Of Urinary Tract
112 50520 Other Or Therapeutic Procedures Of Urinary Tract
112 50525 Other Or Therapeutic Procedures Of Urinary Tract
112 50526 Other Or Therapeutic Procedures Of Urinary Tract
112 50540 Other Or Therapeutic Procedures Of Urinary Tract
112 50541 Other Or Therapeutic Procedures Of Urinary Tract
112 50542 Other Or Therapeutic Procedures Of Urinary Tract
104 50543 Nephrectomy, Partial Or Complete
112 50544 Other Or Therapeutic Procedures Of Urinary Tract
104 50545 Nephrectomy, Partial Or Complete
104 50546 Nephrectomy, Partial Or Complete
104 50547 Nephrectomy, Partial Or Complete
104 50548 Nephrectomy, Partial Or Complete
110 50549 Other Diagnostic Procedures Of Urinary Tract
100 50551 Endoscopy And Endoscopic Biopsy Of The Urinary Tract
100 50553 Endoscopy And Endoscopic Biopsy Of The Urinary Tract
100 50555 Endoscopy And Endoscopic Biopsy Of The Urinary Tract
112 50557 Other Or Therapeutic Procedures Of Urinary Tract
101 50561 Transurethral Excision, Drainage, Or Removal Urinary Obstruction
112 50562 Other Or Therapeutic Procedures Of Urinary Tract
100 50570 Endoscopy And Endoscopic Biopsy Of The Urinary Tract
102 50572 Ureteral Catheterization
100 50574 Endoscopy And Endoscopic Biopsy Of The Urinary Tract
112 50575 Other Or Therapeutic Procedures Of Urinary Tract
112 50576 Other Or Therapeutic Procedures Of Urinary Tract
101 50580 Transurethral Excision, Drainage, Or Removal Urinary Obstruction
107 50590 Extracorporeal Lithotripsy, Urinary
111 50592 Other Non-Or Therapeutic Procedures Of Urinary Tract
112 50593 Other Or Therapeutic Procedures Of Urinary Tract
112 50600 Other Or Therapeutic Procedures Of Urinary Tract
102 50605 Ureteral Catheterization
111 50606 Other Non-Or Therapeutic Procedures Of Urinary Tract
112 50610 Other Or Therapeutic Procedures Of Urinary Tract
112 50620 Other Or Therapeutic Procedures Of Urinary Tract
112 50630 Other Or Therapeutic Procedures Of Urinary Tract
112 50650 Other Or Therapeutic Procedures Of Urinary Tract
112 50660 Other Or Therapeutic Procedures Of Urinary Tract
200 50684 Nonoperative Urinary System Measurements
200 50686 Nonoperative Urinary System Measurements
111 50688 Other Non-Or Therapeutic Procedures Of Urinary Tract
200 50690 Nonoperative Urinary System Measurements
102 50693 Ureteral Catheterization
102 50694 Ureteral Catheterization
102 50695 Ureteral Catheterization
112 50700 Other Or Therapeutic Procedures Of Urinary Tract
111 50705 Other Non-Or Therapeutic Procedures Of Urinary Tract
111 50706 Other Non-Or Therapeutic Procedures Of Urinary Tract
Blue Cross NC Proprietary and Confidential 57 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
112 50715 Other Or Therapeutic Procedures Of Urinary Tract
112 50722 Other Or Therapeutic Procedures Of Urinary Tract
112 50725 Other Or Therapeutic Procedures Of Urinary Tract
112 50727 Other Or Therapeutic Procedures Of Urinary Tract
112 50728 Other Or Therapeutic Procedures Of Urinary Tract
112 50740 Other Or Therapeutic Procedures Of Urinary Tract
112 50750 Other Or Therapeutic Procedures Of Urinary Tract
112 50760 Other Or Therapeutic Procedures Of Urinary Tract
112 50770 Other Or Therapeutic Procedures Of Urinary Tract
112 50780 Other Or Therapeutic Procedures Of Urinary Tract
112 50782 Other Or Therapeutic Procedures Of Urinary Tract
112 50783 Other Or Therapeutic Procedures Of Urinary Tract
112 50785 Other Or Therapeutic Procedures Of Urinary Tract
112 50800 Other Or Therapeutic Procedures Of Urinary Tract
112 50810 Other Or Therapeutic Procedures Of Urinary Tract
112 50815 Other Or Therapeutic Procedures Of Urinary Tract
112 50820 Other Or Therapeutic Procedures Of Urinary Tract
112 50825 Other Or Therapeutic Procedures Of Urinary Tract
112 50830 Other Or Therapeutic Procedures Of Urinary Tract
112 50840 Other Or Therapeutic Procedures Of Urinary Tract
112 50845 Other Or Therapeutic Procedures Of Urinary Tract
112 50860 Other Or Therapeutic Procedures Of Urinary Tract
112 50900 Other Or Therapeutic Procedures Of Urinary Tract
112 50920 Other Or Therapeutic Procedures Of Urinary Tract
112 50930 Other Or Therapeutic Procedures Of Urinary Tract
112 50940 Other Or Therapeutic Procedures Of Urinary Tract
112 50945 Other Or Therapeutic Procedures Of Urinary Tract
102 50947 Ureteral Catheterization
102 50948 Ureteral Catheterization
111 50949 Other Non-Or Therapeutic Procedures Of Urinary Tract
100 50951 Endoscopy And Endoscopic Biopsy Of The Urinary Tract
102 50953 Ureteral Catheterization
100 50955 Endoscopy And Endoscopic Biopsy Of The Urinary Tract
101 50957 Transurethral Excision, Drainage, Or Removal Urinary Obstruction
101 50961 Transurethral Excision, Drainage, Or Removal Urinary Obstruction
100 50970 Endoscopy And Endoscopic Biopsy Of The Urinary Tract
102 50972 Ureteral Catheterization
100 50974 Endoscopy And Endoscopic Biopsy Of The Urinary Tract
101 50976 Transurethral Excision, Drainage, Or Removal Urinary Obstruction
101 50980 Transurethral Excision, Drainage, Or Removal Urinary Obstruction
112 51020 Other Or Therapeutic Procedures Of Urinary Tract
112 51030 Other Or Therapeutic Procedures Of Urinary Tract
112 51040 Other Or Therapeutic Procedures Of Urinary Tract
112 51045 Other Or Therapeutic Procedures Of Urinary Tract
112 51050 Other Or Therapeutic Procedures Of Urinary Tract
112 51060 Other Or Therapeutic Procedures Of Urinary Tract
112 51065 Other Or Therapeutic Procedures Of Urinary Tract
112 51080 Other Or Therapeutic Procedures Of Urinary Tract
111 51100 Other Non-Or Therapeutic Procedures Of Urinary Tract
112 51101 Other Or Therapeutic Procedures Of Urinary Tract
112 51102 Other Or Therapeutic Procedures Of Urinary Tract
112 51500 Other Or Therapeutic Procedures Of Urinary Tract
112 51520 Other Or Therapeutic Procedures Of Urinary Tract
112 51525 Other Or Therapeutic Procedures Of Urinary Tract
112 51530 Other Or Therapeutic Procedures Of Urinary Tract
112 51535 Other Or Therapeutic Procedures Of Urinary Tract
112 51550 Other Or Therapeutic Procedures Of Urinary Tract
112 51555 Other Or Therapeutic Procedures Of Urinary Tract
112 51565 Other Or Therapeutic Procedures Of Urinary Tract
112 51570 Other Or Therapeutic Procedures Of Urinary Tract
112 51575 Other Or Therapeutic Procedures Of Urinary Tract
112 51580 Other Or Therapeutic Procedures Of Urinary Tract
112 51585 Other Or Therapeutic Procedures Of Urinary Tract
112 51590 Other Or Therapeutic Procedures Of Urinary Tract
112 51595 Other Or Therapeutic Procedures Of Urinary Tract
112 51596 Other Or Therapeutic Procedures Of Urinary Tract
112 51597 Other Or Therapeutic Procedures Of Urinary Tract
200 51600 Nonoperative Urinary System Measurements
200 51605 Nonoperative Urinary System Measurements
200 51610 Nonoperative Urinary System Measurements
111 51700 Other Non-Or Therapeutic Procedures Of Urinary Tract
108 51701 Indwelling Catheter
108 51702 Indwelling Catheter
108 51703 Indwelling Catheter
Blue Cross NC Proprietary and Confidential 58 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
111 51705 Other Non-Or Therapeutic Procedures Of Urinary Tract
111 51710 Other Non-Or Therapeutic Procedures Of Urinary Tract
106 51715 Genitourinary Incontinence Procedures
224 51720 Cancer Chemotherapy
200 51725 Nonoperative Urinary System Measurements
200 51726 Nonoperative Urinary System Measurements
200 51727 Nonoperative Urinary System Measurements
200 51728 Nonoperative Urinary System Measurements
200 51729 Nonoperative Urinary System Measurements
200 51736 Nonoperative Urinary System Measurements
200 51741 Nonoperative Urinary System Measurements
200 51784 Nonoperative Urinary System Measurements
200 51785 Nonoperative Urinary System Measurements
200 51792 Nonoperative Urinary System Measurements
200 51797 Nonoperative Urinary System Measurements
200 51798 Nonoperative Urinary System Measurements
112 51800 Other Or Therapeutic Procedures Of Urinary Tract
112 51820 Other Or Therapeutic Procedures Of Urinary Tract
106 51840 Genitourinary Incontinence Procedures
106 51841 Genitourinary Incontinence Procedures
106 51845 Genitourinary Incontinence Procedures
112 51860 Other Or Therapeutic Procedures Of Urinary Tract
112 51865 Other Or Therapeutic Procedures Of Urinary Tract
112 51880 Other Or Therapeutic Procedures Of Urinary Tract
112 51900 Other Or Therapeutic Procedures Of Urinary Tract
112 51920 Other Or Therapeutic Procedures Of Urinary Tract
124 51925 Hysterectomy, Abdominal And Vaginal
112 51940 Other Or Therapeutic Procedures Of Urinary Tract
112 51960 Other Or Therapeutic Procedures Of Urinary Tract
112 51980 Other Or Therapeutic Procedures Of Urinary Tract
106 51990 Genitourinary Incontinence Procedures
106 51992 Genitourinary Incontinence Procedures
110 51999 Other Diagnostic Procedures Of Urinary Tract
100 52000 Endoscopy And Endoscopic Biopsy Of The Urinary Tract
101 52001 Transurethral Excision, Drainage, Or Removal Urinary Obstruction
102 52005 Ureteral Catheterization
100 52007 Endoscopy And Endoscopic Biopsy Of The Urinary Tract
100 52010 Endoscopy And Endoscopic Biopsy Of The Urinary Tract
100 52204 Endoscopy And Endoscopic Biopsy Of The Urinary Tract
101 52214 Transurethral Excision, Drainage, Or Removal Urinary Obstruction
101 52224 Transurethral Excision, Drainage, Or Removal Urinary Obstruction
101 52234 Transurethral Excision, Drainage, Or Removal Urinary Obstruction
101 52235 Transurethral Excision, Drainage, Or Removal Urinary Obstruction
101 52240 Transurethral Excision, Drainage, Or Removal Urinary Obstruction
112 52250 Other Or Therapeutic Procedures Of Urinary Tract
112 52260 Other Or Therapeutic Procedures Of Urinary Tract
112 52265 Other Or Therapeutic Procedures Of Urinary Tract
109 52270 Procedures On The Urethra
109 52275 Procedures On The Urethra
100 52276 Endoscopy And Endoscopic Biopsy Of The Urinary Tract
109 52277 Procedures On The Urethra
109 52281 Procedures On The Urethra
109 52282 Procedures On The Urethra
109 52283 Procedures On The Urethra
109 52285 Procedures On The Urethra
112 52287 Other Or Therapeutic Procedures Of Urinary Tract
109 52290 Procedures On The Urethra
101 52300 Transurethral Excision, Drainage, Or Removal Urinary Obstruction
101 52301 Transurethral Excision, Drainage, Or Removal Urinary Obstruction
101 52305 Transurethral Excision, Drainage, Or Removal Urinary Obstruction
101 52310 Transurethral Excision, Drainage, Or Removal Urinary Obstruction
101 52315 Transurethral Excision, Drainage, Or Removal Urinary Obstruction
112 52317 Other Or Therapeutic Procedures Of Urinary Tract
112 52318 Other Or Therapeutic Procedures Of Urinary Tract
101 52320 Transurethral Excision, Drainage, Or Removal Urinary Obstruction
101 52325 Transurethral Excision, Drainage, Or Removal Urinary Obstruction
112 52327 Other Or Therapeutic Procedures Of Urinary Tract
101 52330 Transurethral Excision, Drainage, Or Removal Urinary Obstruction
102 52332 Ureteral Catheterization
103 52334 Nephrotomy And Nephrostomy
101 52341 Transurethral Excision, Drainage, Or Removal Urinary Obstruction
101 52342 Transurethral Excision, Drainage, Or Removal Urinary Obstruction
101 52343 Transurethral Excision, Drainage, Or Removal Urinary Obstruction
101 52344 Transurethral Excision, Drainage, Or Removal Urinary Obstruction
Blue Cross NC Proprietary and Confidential 59 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
101 52345 Transurethral Excision, Drainage, Or Removal Urinary Obstruction
101 52346 Transurethral Excision, Drainage, Or Removal Urinary Obstruction
100 52351 Endoscopy And Endoscopic Biopsy Of The Urinary Tract
101 52352 Transurethral Excision, Drainage, Or Removal Urinary Obstruction
107 52353 Extracorporeal Lithotripsy, Urinary
100 52354 Endoscopy And Endoscopic Biopsy Of The Urinary Tract
112 52355 Other Or Therapeutic Procedures Of Urinary Tract
107 52356 Extracorporeal Lithotripsy, Urinary
109 52400 Procedures On The Urethra
118 52402 Other Or Therapeutic Procedures, Male Genital
109 52441 Procedures On The Urethra
109 52442 Procedures On The Urethra
118 52450 Other Or Therapeutic Procedures, Male Genital
101 52500 Transurethral Excision, Drainage, Or Removal Urinary Obstruction
113 52601 Transurethral Resection Of Prostate (TURP)
113 52630 Transurethral Resection Of Prostate (TURP)
101 52640 Transurethral Excision, Drainage, Or Removal Urinary Obstruction
118 52647 Other Or Therapeutic Procedures, Male Genital
118 52648 Other Or Therapeutic Procedures, Male Genital
118 52649 Other Or Therapeutic Procedures, Male Genital
118 52700 Other Or Therapeutic Procedures, Male Genital
109 53000 Procedures On The Urethra
109 53010 Procedures On The Urethra
109 53020 Procedures On The Urethra
109 53025 Procedures On The Urethra
109 53040 Procedures On The Urethra
109 53060 Procedures On The Urethra
112 53080 Other Or Therapeutic Procedures Of Urinary Tract
112 53085 Other Or Therapeutic Procedures Of Urinary Tract
100 53200 Endoscopy And Endoscopic Biopsy Of The Urinary Tract
109 53210 Procedures On The Urethra
109 53215 Procedures On The Urethra
109 53220 Procedures On The Urethra
109 53230 Procedures On The Urethra
109 53235 Procedures On The Urethra
109 53240 Procedures On The Urethra
109 53250 Procedures On The Urethra
109 53260 Procedures On The Urethra
109 53265 Procedures On The Urethra
109 53270 Procedures On The Urethra
109 53275 Procedures On The Urethra
109 53400 Procedures On The Urethra
109 53405 Procedures On The Urethra
109 53410 Procedures On The Urethra
109 53415 Procedures On The Urethra
109 53420 Procedures On The Urethra
109 53425 Procedures On The Urethra
109 53430 Procedures On The Urethra
109 53431 Procedures On The Urethra
106 53440 Genitourinary Incontinence Procedures
106 53442 Genitourinary Incontinence Procedures
109 53444 Procedures On The Urethra
106 53445 Genitourinary Incontinence Procedures
109 53446 Procedures On The Urethra
106 53447 Genitourinary Incontinence Procedures
106 53448 Genitourinary Incontinence Procedures
106 53449 Genitourinary Incontinence Procedures
109 53450 Procedures On The Urethra
109 53460 Procedures On The Urethra
109 53500 Procedures On The Urethra
109 53502 Procedures On The Urethra
109 53505 Procedures On The Urethra
109 53510 Procedures On The Urethra
109 53515 Procedures On The Urethra
109 53520 Procedures On The Urethra
109 53600 Procedures On The Urethra
109 53601 Procedures On The Urethra
109 53605 Procedures On The Urethra
109 53620 Procedures On The Urethra
109 53621 Procedures On The Urethra
109 53660 Procedures On The Urethra
109 53661 Procedures On The Urethra
109 53665 Procedures On The Urethra
113 53850 Transurethral Resection Of Prostate (TURP)
Blue Cross NC Proprietary and Confidential 60 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
113 53852 Transurethral Resection Of Prostate (TURP)
113 53854 Transurethral Resection Of Prostate (TURP)
109 53855 Procedures On The Urethra
109 53860 Procedures On The Urethra
112 53899 Other Or Therapeutic Procedures Of Urinary Tract
117 54000 Other Non-Or Therapeutic Procedures, Male Genital
117 54001 Other Non-Or Therapeutic Procedures, Male Genital
118 54015 Other Or Therapeutic Procedures, Male Genital
117 54050 Other Non-Or Therapeutic Procedures, Male Genital
117 54055 Other Non-Or Therapeutic Procedures, Male Genital
117 54056 Other Non-Or Therapeutic Procedures, Male Genital
117 54057 Other Non-Or Therapeutic Procedures, Male Genital
118 54060 Other Or Therapeutic Procedures, Male Genital
118 54065 Other Or Therapeutic Procedures, Male Genital
116 54100 Diagnostic Procedures, Male Genital
116 54105 Diagnostic Procedures, Male Genital
118 54110 Other Or Therapeutic Procedures, Male Genital
118 54111 Other Or Therapeutic Procedures, Male Genital
118 54112 Other Or Therapeutic Procedures, Male Genital
118 54115 Other Or Therapeutic Procedures, Male Genital
118 54120 Other Or Therapeutic Procedures, Male Genital
118 54125 Other Or Therapeutic Procedures, Male Genital
118 54130 Other Or Therapeutic Procedures, Male Genital
118 54135 Other Or Therapeutic Procedures, Male Genital
115 54150 Circumcision
115 54160 Circumcision
115 54161 Circumcision
118 54162 Other Or Therapeutic Procedures, Male Genital
115 54163 Circumcision
118 54164 Other Or Therapeutic Procedures, Male Genital
117 54200 Other Non-Or Therapeutic Procedures, Male Genital
118 54205 Other Or Therapeutic Procedures, Male Genital
118 54220 Other Or Therapeutic Procedures, Male Genital
226 54230 Other Diagnostic Radiology And Related Techniques
116 54231 Diagnostic Procedures, Male Genital
116 54235 Diagnostic Procedures, Male Genital
116 54240 Diagnostic Procedures, Male Genital
116 54250 Diagnostic Procedures, Male Genital
118 54300 Other Or Therapeutic Procedures, Male Genital
118 54304 Other Or Therapeutic Procedures, Male Genital
109 54308 Procedures On The Urethra
109 54312 Procedures On The Urethra
109 54316 Procedures On The Urethra
109 54318 Procedures On The Urethra
118 54322 Other Or Therapeutic Procedures, Male Genital
118 54324 Other Or Therapeutic Procedures, Male Genital
118 54326 Other Or Therapeutic Procedures, Male Genital
118 54328 Other Or Therapeutic Procedures, Male Genital
118 54332 Other Or Therapeutic Procedures, Male Genital
118 54336 Other Or Therapeutic Procedures, Male Genital
118 54340 Other Or Therapeutic Procedures, Male Genital
118 54344 Other Or Therapeutic Procedures, Male Genital
118 54348 Other Or Therapeutic Procedures, Male Genital
118 54352 Other Or Therapeutic Procedures, Male Genital
118 54360 Other Or Therapeutic Procedures, Male Genital
118 54380 Other Or Therapeutic Procedures, Male Genital
118 54385 Other Or Therapeutic Procedures, Male Genital
118 54390 Other Or Therapeutic Procedures, Male Genital
118 54400 Other Or Therapeutic Procedures, Male Genital
118 54401 Other Or Therapeutic Procedures, Male Genital
118 54405 Other Or Therapeutic Procedures, Male Genital
118 54406 Other Or Therapeutic Procedures, Male Genital
118 54408 Other Or Therapeutic Procedures, Male Genital
118 54410 Other Or Therapeutic Procedures, Male Genital
118 54411 Other Or Therapeutic Procedures, Male Genital
118 54415 Other Or Therapeutic Procedures, Male Genital
118 54416 Other Or Therapeutic Procedures, Male Genital
118 54417 Other Or Therapeutic Procedures, Male Genital
118 54420 Other Or Therapeutic Procedures, Male Genital
118 54430 Other Or Therapeutic Procedures, Male Genital
118 54435 Other Or Therapeutic Procedures, Male Genital
118 54437 Other Or Therapeutic Procedures, Male Genital
118 54438 Other Or Therapeutic Procedures, Male Genital
118 54440 Other Or Therapeutic Procedures, Male Genital
Blue Cross NC Proprietary and Confidential 61 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
117 54450 Other Non-Or Therapeutic Procedures, Male Genital
116 54500 Diagnostic Procedures, Male Genital
116 54505 Diagnostic Procedures, Male Genital
118 54512 Other Or Therapeutic Procedures, Male Genital
118 54520 Other Or Therapeutic Procedures, Male Genital
118 54522 Other Or Therapeutic Procedures, Male Genital
118 54530 Other Or Therapeutic Procedures, Male Genital
118 54535 Other Or Therapeutic Procedures, Male Genital
118 54550 Other Or Therapeutic Procedures, Male Genital
118 54560 Other Or Therapeutic Procedures, Male Genital
118 54600 Other Or Therapeutic Procedures, Male Genital
118 54620 Other Or Therapeutic Procedures, Male Genital
118 54640 Other Or Therapeutic Procedures, Male Genital
118 54650 Other Or Therapeutic Procedures, Male Genital
118 54660 Other Or Therapeutic Procedures, Male Genital
118 54670 Other Or Therapeutic Procedures, Male Genital
118 54680 Other Or Therapeutic Procedures, Male Genital
118 54690 Other Or Therapeutic Procedures, Male Genital
118 54692 Other Or Therapeutic Procedures, Male Genital
116 54699 Diagnostic Procedures, Male Genital
118 54700 Other Or Therapeutic Procedures, Male Genital
116 54800 Diagnostic Procedures, Male Genital
118 54830 Other Or Therapeutic Procedures, Male Genital
118 54840 Other Or Therapeutic Procedures, Male Genital
118 54860 Other Or Therapeutic Procedures, Male Genital
118 54861 Other Or Therapeutic Procedures, Male Genital
116 54865 Diagnostic Procedures, Male Genital
118 54900 Other Or Therapeutic Procedures, Male Genital
118 54901 Other Or Therapeutic Procedures, Male Genital
117 55000 Other Non-Or Therapeutic Procedures, Male Genital
118 55040 Other Or Therapeutic Procedures, Male Genital
118 55041 Other Or Therapeutic Procedures, Male Genital
118 55060 Other Or Therapeutic Procedures, Male Genital
117 55100 Other Non-Or Therapeutic Procedures, Male Genital
116 55110 Diagnostic Procedures, Male Genital
117 55120 Other Non-Or Therapeutic Procedures, Male Genital
118 55150 Other Or Therapeutic Procedures, Male Genital
118 55175 Other Or Therapeutic Procedures, Male Genital
118 55180 Other Or Therapeutic Procedures, Male Genital
117 55200 Other Non-Or Therapeutic Procedures, Male Genital
117 55250 Other Non-Or Therapeutic Procedures, Male Genital
226 55300 Other Diagnostic Radiology And Related Techniques
118 55400 Other Or Therapeutic Procedures, Male Genital
118 55500 Other Or Therapeutic Procedures, Male Genital
118 55520 Other Or Therapeutic Procedures, Male Genital
118 55530 Other Or Therapeutic Procedures, Male Genital
118 55535 Other Or Therapeutic Procedures, Male Genital
86 55540 Other Hernia Repair
118 55550 Other Or Therapeutic Procedures, Male Genital
118 55559 Other Or Therapeutic Procedures, Male Genital
118 55600 Other Or Therapeutic Procedures, Male Genital
118 55605 Other Or Therapeutic Procedures, Male Genital
118 55650 Other Or Therapeutic Procedures, Male Genital
118 55680 Other Or Therapeutic Procedures, Male Genital
116 55700 Diagnostic Procedures, Male Genital
116 55705 Diagnostic Procedures, Male Genital
116 55706 Diagnostic Procedures, Male Genital
118 55720 Other Or Therapeutic Procedures, Male Genital
118 55725 Other Or Therapeutic Procedures, Male Genital
114 55801 Open Prostatectomy
114 55810 Open Prostatectomy
114 55812 Open Prostatectomy
114 55815 Open Prostatectomy
114 55821 Open Prostatectomy
114 55831 Open Prostatectomy
114 55840 Open Prostatectomy
114 55842 Open Prostatectomy
114 55845 Open Prostatectomy
118 55860 Other Or Therapeutic Procedures, Male Genital
118 55862 Other Or Therapeutic Procedures, Male Genital
118 55865 Other Or Therapeutic Procedures, Male Genital
114 55866 Open Prostatectomy
117 55870 Other Non-Or Therapeutic Procedures, Male Genital
114 55873 Open Prostatectomy
Blue Cross NC Proprietary and Confidential 62 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
211 55874 Therapeutic Radiology
117 55875 Other Non-Or Therapeutic Procedures, Male Genital
117 55876 Other Non-Or Therapeutic Procedures, Male Genital
118 55899 Other Or Therapeutic Procedures, Male Genital
117 55920 Other Non-Or Therapeutic Procedures, Male Genital
118 55970 Other Or Therapeutic Procedures, Male Genital
132 55980 Other Or Therapeutic Procedures, Female Organs
132 56405 Other Or Therapeutic Procedures, Female Organs
132 56420 Other Or Therapeutic Procedures, Female Organs
132 56440 Other Or Therapeutic Procedures, Female Organs
132 56441 Other Or Therapeutic Procedures, Female Organs
132 56442 Other Or Therapeutic Procedures, Female Organs
132 56501 Other Or Therapeutic Procedures, Female Organs
132 56515 Other Or Therapeutic Procedures, Female Organs
130 56605 Other Diagnostic Procedures, Female Organs
130 56606 Other Diagnostic Procedures, Female Organs
132 56620 Other Or Therapeutic Procedures, Female Organs
132 56625 Other Or Therapeutic Procedures, Female Organs
132 56630 Other Or Therapeutic Procedures, Female Organs
132 56631 Other Or Therapeutic Procedures, Female Organs
132 56632 Other Or Therapeutic Procedures, Female Organs
132 56633 Other Or Therapeutic Procedures, Female Organs
132 56634 Other Or Therapeutic Procedures, Female Organs
132 56637 Other Or Therapeutic Procedures, Female Organs
132 56640 Other Or Therapeutic Procedures, Female Organs
132 56700 Other Or Therapeutic Procedures, Female Organs
132 56740 Other Or Therapeutic Procedures, Female Organs
132 56800 Other Or Therapeutic Procedures, Female Organs
132 56805 Other Or Therapeutic Procedures, Female Organs
132 56810 Other Or Therapeutic Procedures, Female Organs
130 56820 Other Diagnostic Procedures, Female Organs
130 56821 Other Diagnostic Procedures, Female Organs
130 57000 Other Diagnostic Procedures, Female Organs
132 57010 Other Or Therapeutic Procedures, Female Organs
131 57020 Other Non-Or Therapeutic Procedures, Female Organs
141 57022 Other Therapeutic Obstetrical Procedures
132 57023 Other Or Therapeutic Procedures, Female Organs
131 57061 Other Non-Or Therapeutic Procedures, Female Organs
132 57065 Other Or Therapeutic Procedures, Female Organs
130 57100 Other Diagnostic Procedures, Female Organs
130 57105 Other Diagnostic Procedures, Female Organs
132 57106 Other Or Therapeutic Procedures, Female Organs
132 57107 Other Or Therapeutic Procedures, Female Organs
132 57109 Other Or Therapeutic Procedures, Female Organs
132 57110 Other Or Therapeutic Procedures, Female Organs
132 57111 Other Or Therapeutic Procedures, Female Organs
132 57112 Other Or Therapeutic Procedures, Female Organs
129 57120 Repair Of Cystocele And Rectocele, Obliteration Of Vaginal Vault
132 57130 Other Or Therapeutic Procedures, Female Organs
132 57135 Other Or Therapeutic Procedures, Female Organs
131 57150 Other Non-Or Therapeutic Procedures, Female Organs
132 57155 Other Or Therapeutic Procedures, Female Organs
131 57156 Other Non-Or Therapeutic Procedures, Female Organs
131 57160 Other Non-Or Therapeutic Procedures, Female Organs
131 57170 Other Non-Or Therapeutic Procedures, Female Organs
131 57180 Other Non-Or Therapeutic Procedures, Female Organs
132 57200 Other Or Therapeutic Procedures, Female Organs
132 57210 Other Or Therapeutic Procedures, Female Organs
106 57220 Genitourinary Incontinence Procedures
129 57230 Repair Of Cystocele And Rectocele, Obliteration Of Vaginal Vault
129 57240 Repair Of Cystocele And Rectocele, Obliteration Of Vaginal Vault
129 57250 Repair Of Cystocele And Rectocele, Obliteration Of Vaginal Vault
129 57260 Repair Of Cystocele And Rectocele, Obliteration Of Vaginal Vault
129 57265 Repair Of Cystocele And Rectocele, Obliteration Of Vaginal Vault
129 57267 Repair Of Cystocele And Rectocele, Obliteration Of Vaginal Vault
129 57268 Repair Of Cystocele And Rectocele, Obliteration Of Vaginal Vault
129 57270 Repair Of Cystocele And Rectocele, Obliteration Of Vaginal Vault
132 57280 Other Or Therapeutic Procedures, Female Organs
132 57282 Other Or Therapeutic Procedures, Female Organs
132 57283 Other Or Therapeutic Procedures, Female Organs
129 57284 Repair Of Cystocele And Rectocele, Obliteration Of Vaginal Vault
129 57285 Repair Of Cystocele And Rectocele, Obliteration Of Vaginal Vault
106 57287 Genitourinary Incontinence Procedures
106 57288 Genitourinary Incontinence Procedures
Blue Cross NC Proprietary and Confidential 63 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
129 57289 Repair Of Cystocele And Rectocele, Obliteration Of Vaginal Vault
132 57291 Other Or Therapeutic Procedures, Female Organs
132 57292 Other Or Therapeutic Procedures, Female Organs
132 57295 Other Or Therapeutic Procedures, Female Organs
132 57296 Other Or Therapeutic Procedures, Female Organs
132 57300 Other Or Therapeutic Procedures, Female Organs
132 57305 Other Or Therapeutic Procedures, Female Organs
72 57307 Colostomy, Temporary And Permanent
132 57308 Other Or Therapeutic Procedures, Female Organs
109 57310 Procedures On The Urethra
109 57311 Procedures On The Urethra
112 57320 Other Or Therapeutic Procedures Of Urinary Tract
112 57330 Other Or Therapeutic Procedures Of Urinary Tract
132 57335 Other Or Therapeutic Procedures, Female Organs
131 57400 Other Non-Or Therapeutic Procedures, Female Organs
130 57410 Other Diagnostic Procedures, Female Organs
229 57415 Nonoperative Removal Of Foreign Body
130 57420 Other Diagnostic Procedures, Female Organs
130 57421 Other Diagnostic Procedures, Female Organs
129 57423 Repair Of Cystocele And Rectocele, Obliteration Of Vaginal Vault
132 57425 Other Or Therapeutic Procedures, Female Organs
132 57426 Other Or Therapeutic Procedures, Female Organs
130 57452 Other Diagnostic Procedures, Female Organs
130 57454 Other Diagnostic Procedures, Female Organs
130 57455 Other Diagnostic Procedures, Female Organs
130 57456 Other Diagnostic Procedures, Female Organs
130 57460 Other Diagnostic Procedures, Female Organs
125 57461 Other Excision Of Cervix And Uterus
130 57500 Other Diagnostic Procedures, Female Organs
132 57505 Other Or Therapeutic Procedures, Female Organs
125 57510 Other Excision Of Cervix And Uterus
125 57511 Other Excision Of Cervix And Uterus
125 57513 Other Excision Of Cervix And Uterus
125 57520 Other Excision Of Cervix And Uterus
125 57522 Other Excision Of Cervix And Uterus
125 57530 Other Excision Of Cervix And Uterus
125 57531 Other Excision Of Cervix And Uterus
125 57540 Other Excision Of Cervix And Uterus
125 57545 Other Excision Of Cervix And Uterus
125 57550 Other Excision Of Cervix And Uterus
129 57555 Repair Of Cystocele And Rectocele, Obliteration Of Vaginal Vault
129 57556 Repair Of Cystocele And Rectocele, Obliteration Of Vaginal Vault
125 57558 Other Excision Of Cervix And Uterus
132 57700 Other Or Therapeutic Procedures, Female Organs
132 57720 Other Or Therapeutic Procedures, Female Organs
131 57800 Other Non-Or Therapeutic Procedures, Female Organs
130 58100 Other Diagnostic Procedures, Female Organs
130 58110 Other Diagnostic Procedures, Female Organs
128 58120 Diagnostic Dilatation And Curettage (D&C)
125 58140 Other Excision Of Cervix And Uterus
125 58145 Other Excision Of Cervix And Uterus
125 58146 Other Excision Of Cervix And Uterus
124 58150 Hysterectomy, Abdominal And Vaginal
124 58152 Hysterectomy, Abdominal And Vaginal
124 58180 Hysterectomy, Abdominal And Vaginal
124 58200 Hysterectomy, Abdominal And Vaginal
124 58210 Hysterectomy, Abdominal And Vaginal
124 58240 Hysterectomy, Abdominal And Vaginal
124 58260 Hysterectomy, Abdominal And Vaginal
124 58262 Hysterectomy, Abdominal And Vaginal
124 58263 Hysterectomy, Abdominal And Vaginal
124 58267 Hysterectomy, Abdominal And Vaginal
124 58270 Hysterectomy, Abdominal And Vaginal
124 58275 Hysterectomy, Abdominal And Vaginal
124 58280 Hysterectomy, Abdominal And Vaginal
124 58285 Hysterectomy, Abdominal And Vaginal
124 58290 Hysterectomy, Abdominal And Vaginal
124 58291 Hysterectomy, Abdominal And Vaginal
124 58292 Hysterectomy, Abdominal And Vaginal
124 58293 Hysterectomy, Abdominal And Vaginal
124 58294 Hysterectomy, Abdominal And Vaginal
131 58300 Other Non-Or Therapeutic Procedures, Female Organs
131 58301 Other Non-Or Therapeutic Procedures, Female Organs
131 58321 Other Non-Or Therapeutic Procedures, Female Organs
Blue Cross NC Proprietary and Confidential 64 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
131 58322 Other Non-Or Therapeutic Procedures, Female Organs
131 58323 Other Non-Or Therapeutic Procedures, Female Organs
130 58340 Other Diagnostic Procedures, Female Organs
123 58345 Other Operations On Fallopian Tubes
132 58346 Other Or Therapeutic Procedures, Female Organs
123 58350 Other Operations On Fallopian Tubes
125 58353 Other Excision Of Cervix And Uterus
125 58356 Other Excision Of Cervix And Uterus
132 58400 Other Or Therapeutic Procedures, Female Organs
132 58410 Other Or Therapeutic Procedures, Female Organs
132 58520 Other Or Therapeutic Procedures, Female Organs
132 58540 Other Or Therapeutic Procedures, Female Organs
124 58541 Hysterectomy, Abdominal And Vaginal
124 58542 Hysterectomy, Abdominal And Vaginal
124 58543 Hysterectomy, Abdominal And Vaginal
124 58544 Hysterectomy, Abdominal And Vaginal
125 58545 Other Excision Of Cervix And Uterus
125 58546 Other Excision Of Cervix And Uterus
124 58548 Hysterectomy, Abdominal And Vaginal
124 58550 Hysterectomy, Abdominal And Vaginal
124 58552 Hysterectomy, Abdominal And Vaginal
124 58553 Hysterectomy, Abdominal And Vaginal
124 58554 Hysterectomy, Abdominal And Vaginal
130 58555 Other Diagnostic Procedures, Female Organs
130 58558 Other Diagnostic Procedures, Female Organs
125 58559 Other Excision Of Cervix And Uterus
125 58560 Other Excision Of Cervix And Uterus
125 58561 Other Excision Of Cervix And Uterus
229 58562 Nonoperative Removal Of Foreign Body
125 58563 Other Excision Of Cervix And Uterus
123 58565 Other Operations On Fallopian Tubes
124 58570 Hysterectomy, Abdominal And Vaginal
124 58571 Hysterectomy, Abdominal And Vaginal
124 58572 Hysterectomy, Abdominal And Vaginal
124 58573 Hysterectomy, Abdominal And Vaginal
124 58575 Hysterectomy, Abdominal And Vaginal
130 58578 Other Diagnostic Procedures, Female Organs
130 58579 Other Diagnostic Procedures, Female Organs
121 58600 Ligation Of Fallopian Tubes
121 58605 Ligation Of Fallopian Tubes
121 58611 Ligation Of Fallopian Tubes
121 58615 Ligation Of Fallopian Tubes
132 58660 Other Or Therapeutic Procedures, Female Organs
119 58661 Oophorectomy, Unilateral And Bilateral
132 58662 Other Or Therapeutic Procedures, Female Organs
121 58670 Ligation Of Fallopian Tubes
121 58671 Ligation Of Fallopian Tubes
123 58672 Other Operations On Fallopian Tubes
132 58673 Other Or Therapeutic Procedures, Female Organs
132 58674 Other Or Therapeutic Procedures, Female Organs
130 58679 Other Diagnostic Procedures, Female Organs
123 58700 Other Operations On Fallopian Tubes
119 58720 Oophorectomy, Unilateral And Bilateral
120 58740 Other Operations On Ovary
123 58750 Other Operations On Fallopian Tubes
123 58752 Other Operations On Fallopian Tubes
123 58760 Other Operations On Fallopian Tubes
123 58770 Other Operations On Fallopian Tubes
120 58800 Other Operations On Ovary
120 58805 Other Operations On Ovary
120 58820 Other Operations On Ovary
120 58822 Other Operations On Ovary
120 58825 Other Operations On Ovary
130 58900 Other Diagnostic Procedures, Female Organs
120 58920 Other Operations On Ovary
120 58925 Other Operations On Ovary
119 58940 Oophorectomy, Unilateral And Bilateral
119 58943 Oophorectomy, Unilateral And Bilateral
119 58950 Oophorectomy, Unilateral And Bilateral
124 58951 Hysterectomy, Abdominal And Vaginal
119 58952 Oophorectomy, Unilateral And Bilateral
124 58953 Hysterectomy, Abdominal And Vaginal
124 58954 Hysterectomy, Abdominal And Vaginal
124 58956 Hysterectomy, Abdominal And Vaginal
Blue Cross NC Proprietary and Confidential 65 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
132 58957 Other Or Therapeutic Procedures, Female Organs
132 58958 Other Or Therapeutic Procedures, Female Organs
130 58960 Other Diagnostic Procedures, Female Organs
120 58970 Other Operations On Ovary
132 58974 Other Or Therapeutic Procedures, Female Organs
132 58976 Other Or Therapeutic Procedures, Female Organs
132 58999 Other Or Therapeutic Procedures, Female Organs
138 59000 Diagnostic Amniocentesis
141 59001 Other Therapeutic Obstetrical Procedures
139 59012 Fetal Monitoring
139 59015 Fetal Monitoring
139 59020 Fetal Monitoring
139 59025 Fetal Monitoring
139 59030 Fetal Monitoring
139 59050 Fetal Monitoring
139 59051 Fetal Monitoring
141 59070 Other Therapeutic Obstetrical Procedures
141 59072 Other Therapeutic Obstetrical Procedures
141 59074 Other Therapeutic Obstetrical Procedures
141 59076 Other Therapeutic Obstetrical Procedures
132 59100 Other Or Therapeutic Procedures, Female Organs
122 59120 Removal Of Ectopic Pregnancy
122 59121 Removal Of Ectopic Pregnancy
122 59130 Removal Of Ectopic Pregnancy
122 59135 Removal Of Ectopic Pregnancy
122 59136 Removal Of Ectopic Pregnancy
122 59140 Removal Of Ectopic Pregnancy
122 59150 Removal Of Ectopic Pregnancy
122 59151 Removal Of Ectopic Pregnancy
127 59160 Dilatation And Curettage (D&C), Aspiration After Delivery Or Abortion
141 59200 Other Therapeutic Obstetrical Procedures
140 59300 Repair Of Current Obstetric Laceration
141 59320 Other Therapeutic Obstetrical Procedures
141 59325 Other Therapeutic Obstetrical Procedures
140 59350 Repair Of Current Obstetric Laceration
135 59400 Forceps, Vacuum, And Breech Delivery
135 59409 Forceps, Vacuum, And Breech Delivery
135 59410 Forceps, Vacuum, And Breech Delivery
137 59412 Other Procedures To Assist Delivery
137 59414 Other Procedures To Assist Delivery
227 59425 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 59426 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 59430 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
134 59510 Cesarean Section
134 59514 Cesarean Section
134 59515 Cesarean Section
124 59525 Hysterectomy, Abdominal And Vaginal
135 59610 Forceps, Vacuum, And Breech Delivery
135 59612 Forceps, Vacuum, And Breech Delivery
135 59614 Forceps, Vacuum, And Breech Delivery
134 59618 Cesarean Section
134 59620 Cesarean Section
134 59622 Cesarean Section
127 59812 Dilatation And Curettage (D&C), Aspiration After Delivery Or Abortion
127 59820 Dilatation And Curettage (D&C), Aspiration After Delivery Or Abortion
127 59821 Dilatation And Curettage (D&C), Aspiration After Delivery Or Abortion
127 59830 Dilatation And Curettage (D&C), Aspiration After Delivery Or Abortion
126 59840 Abortion (Termination Of Pregnancy)
126 59841 Abortion (Termination Of Pregnancy)
126 59850 Abortion (Termination Of Pregnancy)
126 59851 Abortion (Termination Of Pregnancy)
126 59852 Abortion (Termination Of Pregnancy)
126 59855 Abortion (Termination Of Pregnancy)
126 59856 Abortion (Termination Of Pregnancy)
126 59857 Abortion (Termination Of Pregnancy)
141 59866 Other Therapeutic Obstetrical Procedures
132 59870 Other Or Therapeutic Procedures, Female Organs
131 59871 Other Non-Or Therapeutic Procedures, Female Organs
141 59897 Other Therapeutic Obstetrical Procedures
141 59898 Other Therapeutic Obstetrical Procedures
137 59899 Other Procedures To Assist Delivery
12 60000 Other Therapeutic Endocrine Procedures
11 60100 Diagnostic Endocrine Procedures
12 60200 Other Therapeutic Endocrine Procedures
Blue Cross NC Proprietary and Confidential 66 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
10 60210 Thyroidectomy, Partial Or Complete
10 60212 Thyroidectomy, Partial Or Complete
10 60220 Thyroidectomy, Partial Or Complete
10 60225 Thyroidectomy, Partial Or Complete
10 60240 Thyroidectomy, Partial Or Complete
10 60252 Thyroidectomy, Partial Or Complete
10 60254 Thyroidectomy, Partial Or Complete
10 60260 Thyroidectomy, Partial Or Complete
10 60270 Thyroidectomy, Partial Or Complete
10 60271 Thyroidectomy, Partial Or Complete
12 60280 Other Therapeutic Endocrine Procedures
12 60281 Other Therapeutic Endocrine Procedures
12 60300 Other Therapeutic Endocrine Procedures
12 60500 Other Therapeutic Endocrine Procedures
12 60502 Other Therapeutic Endocrine Procedures
12 60505 Other Therapeutic Endocrine Procedures
12 60512 Other Therapeutic Endocrine Procedures
12 60520 Other Therapeutic Endocrine Procedures
12 60521 Other Therapeutic Endocrine Procedures
12 60522 Other Therapeutic Endocrine Procedures
12 60540 Other Therapeutic Endocrine Procedures
12 60545 Other Therapeutic Endocrine Procedures
59 60600 Other Or Procedures On Vessels Of Head And Neck
59 60605 Other Or Procedures On Vessels Of Head And Neck
12 60650 Other Therapeutic Endocrine Procedures
12 60659 Other Therapeutic Endocrine Procedures
12 60699 Other Therapeutic Endocrine Procedures
1 61000 Incision And Excision Of CNS
1 61001 Incision And Excision Of CNS
1 61020 Incision And Excision Of CNS
1 61026 Incision And Excision Of CNS
1 61050 Incision And Excision Of CNS
1 61055 Incision And Excision Of CNS
8 61070 Other Non-Or Or Closed Therapeutic Nervous System Procedures
1 61105 Incision And Excision Of CNS
2 61107 Insertion, Replacement, Or Removal Of Extracranial Ventricular Shunt
1 61108 Incision And Excision Of CNS
1 61120 Incision And Excision Of CNS
7 61140 Other Diagnostic Nervous System Procedures
1 61150 Incision And Excision Of CNS
1 61151 Incision And Excision Of CNS
1 61154 Incision And Excision Of CNS
1 61156 Incision And Excision Of CNS
2 61210 Insertion, Replacement, Or Removal Of Extracranial Ventricular Shunt
175 61215 Other Or Therapeutic Procedures On Skin And Breast
1 61250 Incision And Excision Of CNS
1 61253 Incision And Excision Of CNS
1 61304 Incision And Excision Of CNS
1 61305 Incision And Excision Of CNS
1 61312 Incision And Excision Of CNS
1 61313 Incision And Excision Of CNS
1 61314 Incision And Excision Of CNS
1 61315 Incision And Excision Of CNS
161 61316 Other Or Therapeutic Procedures On Bone
1 61320 Incision And Excision Of CNS
1 61321 Incision And Excision Of CNS
1 61322 Incision And Excision Of CNS
1 61323 Incision And Excision Of CNS
21 61330 Other Extraocular Muscle And Orbit Therapeutic Procedures
21 61333 Other Extraocular Muscle And Orbit Therapeutic Procedures
1 61340 Incision And Excision Of CNS
3 61343 Laminectomy, Excision Intervertebral Disc
1 61345 Incision And Excision Of CNS
9 61450 Other Or Therapeutic Nervous System Procedures
9 61458 Other Or Therapeutic Nervous System Procedures
9 61460 Other Or Therapeutic Nervous System Procedures
9 61500 Other Or Therapeutic Nervous System Procedures
9 61501 Other Or Therapeutic Nervous System Procedures
1 61510 Incision And Excision Of CNS
1 61512 Incision And Excision Of CNS
1 61514 Incision And Excision Of CNS
1 61516 Incision And Excision Of CNS
224 61517 Cancer Chemotherapy
1 61518 Incision And Excision Of CNS
Blue Cross NC Proprietary and Confidential 67 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
1 61519 Incision And Excision Of CNS
1 61520 Incision And Excision Of CNS
1 61521 Incision And Excision Of CNS
1 61522 Incision And Excision Of CNS
1 61524 Incision And Excision Of CNS
1 61526 Incision And Excision Of CNS
1 61530 Incision And Excision Of CNS
9 61531 Other Or Therapeutic Nervous System Procedures
9 61533 Other Or Therapeutic Nervous System Procedures
1 61534 Incision And Excision Of CNS
1 61535 Incision And Excision Of CNS
1 61536 Incision And Excision Of CNS
1 61537 Incision And Excision Of CNS
1 61538 Incision And Excision Of CNS
1 61539 Incision And Excision Of CNS
1 61540 Incision And Excision Of CNS
1 61541 Incision And Excision Of CNS
1 61543 Incision And Excision Of CNS
1 61544 Incision And Excision Of CNS
1 61545 Incision And Excision Of CNS
12 61546 Other Therapeutic Endocrine Procedures
12 61548 Other Therapeutic Endocrine Procedures
9 61550 Other Or Therapeutic Nervous System Procedures
9 61552 Other Or Therapeutic Nervous System Procedures
1 61556 Incision And Excision Of CNS
1 61557 Incision And Excision Of CNS
9 61558 Other Or Therapeutic Nervous System Procedures
9 61559 Other Or Therapeutic Nervous System Procedures
9 61563 Other Or Therapeutic Nervous System Procedures
9 61564 Other Or Therapeutic Nervous System Procedures
9 61566 Other Or Therapeutic Nervous System Procedures
9 61567 Other Or Therapeutic Nervous System Procedures
1 61570 Incision And Excision Of CNS
1 61571 Incision And Excision Of CNS
1 61575 Incision And Excision Of CNS
1 61576 Incision And Excision Of CNS
9 61580 Other Or Therapeutic Nervous System Procedures
9 61581 Other Or Therapeutic Nervous System Procedures
1 61582 Incision And Excision Of CNS
1 61583 Incision And Excision Of CNS
1 61584 Incision And Excision Of CNS
1 61585 Incision And Excision Of CNS
1 61586 Incision And Excision Of CNS
1 61590 Incision And Excision Of CNS
1 61591 Incision And Excision Of CNS
1 61592 Incision And Excision Of CNS
1 61595 Incision And Excision Of CNS
1 61596 Incision And Excision Of CNS
142 61597 Partial Excision Bone
1 61598 Incision And Excision Of CNS
1 61600 Incision And Excision Of CNS
1 61601 Incision And Excision Of CNS
1 61605 Incision And Excision Of CNS
1 61606 Incision And Excision Of CNS
1 61607 Incision And Excision Of CNS
1 61608 Incision And Excision Of CNS
59 61611 Other Or Procedures On Vessels Of Head And Neck
59 61613 Other Or Procedures On Vessels Of Head And Neck
1 61615 Incision And Excision Of CNS
1 61616 Incision And Excision Of CNS
9 61618 Other Or Therapeutic Nervous System Procedures
9 61619 Other Or Therapeutic Nervous System Procedures
59 61623 Other Or Procedures On Vessels Of Head And Neck
59 61624 Other Or Procedures On Vessels Of Head And Neck
59 61626 Other Or Procedures On Vessels Of Head And Neck
59 61630 Other Or Procedures On Vessels Of Head And Neck
59 61635 Other Or Procedures On Vessels Of Head And Neck
59 61640 Other Or Procedures On Vessels Of Head And Neck
59 61641 Other Or Procedures On Vessels Of Head And Neck
59 61642 Other Or Procedures On Vessels Of Head And Neck
59 61645 Other Or Procedures On Vessels Of Head And Neck
54 61650 Other Vascular Catheterization, Not Heart
54 61651 Other Vascular Catheterization, Not Heart
59 61680 Other Or Procedures On Vessels Of Head And Neck
Blue Cross NC Proprietary and Confidential 68 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
59 61682 Other Or Procedures On Vessels Of Head And Neck
59 61684 Other Or Procedures On Vessels Of Head And Neck
59 61686 Other Or Procedures On Vessels Of Head And Neck
59 61690 Other Or Procedures On Vessels Of Head And Neck
59 61692 Other Or Procedures On Vessels Of Head And Neck
59 61697 Other Or Procedures On Vessels Of Head And Neck
59 61698 Other Or Procedures On Vessels Of Head And Neck
59 61700 Other Or Procedures On Vessels Of Head And Neck
59 61702 Other Or Procedures On Vessels Of Head And Neck
59 61703 Other Or Procedures On Vessels Of Head And Neck
59 61705 Other Or Procedures On Vessels Of Head And Neck
59 61708 Other Or Procedures On Vessels Of Head And Neck
59 61710 Other Or Procedures On Vessels Of Head And Neck
59 61711 Other Or Procedures On Vessels Of Head And Neck
1 61720 Incision And Excision Of CNS
1 61735 Incision And Excision Of CNS
7 61750 Other Diagnostic Nervous System Procedures
7 61751 Other Diagnostic Nervous System Procedures
9 61760 Other Or Therapeutic Nervous System Procedures
9 61770 Other Or Therapeutic Nervous System Procedures
9 61781 Other Or Therapeutic Nervous System Procedures
9 61782 Other Or Therapeutic Nervous System Procedures
9 61783 Other Or Therapeutic Nervous System Procedures
9 61790 Other Or Therapeutic Nervous System Procedures
9 61791 Other Or Therapeutic Nervous System Procedures
9 61796 Other Or Therapeutic Nervous System Procedures
9 61797 Other Or Therapeutic Nervous System Procedures
9 61798 Other Or Therapeutic Nervous System Procedures
9 61799 Other Or Therapeutic Nervous System Procedures
9 61800 Other Or Therapeutic Nervous System Procedures
9 61850 Other Or Therapeutic Nervous System Procedures
9 61860 Other Or Therapeutic Nervous System Procedures
9 61863 Other Or Therapeutic Nervous System Procedures
9 61864 Other Or Therapeutic Nervous System Procedures
9 61867 Other Or Therapeutic Nervous System Procedures
9 61868 Other Or Therapeutic Nervous System Procedures
9 61870 Other Or Therapeutic Nervous System Procedures
1 61880 Incision And Excision Of CNS
174 61885 Other Non-Or Therapeutic Procedures On Skin And Breast
174 61886 Other Non-Or Therapeutic Procedures On Skin And Breast
174 61888 Other Non-Or Therapeutic Procedures On Skin And Breast
148 62000 Other Fracture And Dislocation Procedure
148 62005 Other Fracture And Dislocation Procedure
148 62010 Other Fracture And Dislocation Procedure
9 62100 Other Or Therapeutic Nervous System Procedures
9 62115 Other Or Therapeutic Nervous System Procedures
9 62117 Other Or Therapeutic Nervous System Procedures
9 62120 Other Or Therapeutic Nervous System Procedures
9 62121 Other Or Therapeutic Nervous System Procedures
9 62140 Other Or Therapeutic Nervous System Procedures
9 62141 Other Or Therapeutic Nervous System Procedures
9 62142 Other Or Therapeutic Nervous System Procedures
9 62143 Other Or Therapeutic Nervous System Procedures
9 62145 Other Or Therapeutic Nervous System Procedures
9 62146 Other Or Therapeutic Nervous System Procedures
9 62147 Other Or Therapeutic Nervous System Procedures
9 62148 Other Or Therapeutic Nervous System Procedures
2 62160 Insertion, Replacement, Or Removal Of Extracranial Ventricular Shunt
1 62161 Incision And Excision Of CNS
1 62162 Incision And Excision Of CNS
1 62163 Incision And Excision Of CNS
1 62164 Incision And Excision Of CNS
12 62165 Other Therapeutic Endocrine Procedures
2 62180 Insertion, Replacement, Or Removal Of Extracranial Ventricular Shunt
2 62190 Insertion, Replacement, Or Removal Of Extracranial Ventricular Shunt
2 62192 Insertion, Replacement, Or Removal Of Extracranial Ventricular Shunt
2 62194 Insertion, Replacement, Or Removal Of Extracranial Ventricular Shunt
2 62200 Insertion, Replacement, Or Removal Of Extracranial Ventricular Shunt
2 62201 Insertion, Replacement, Or Removal Of Extracranial Ventricular Shunt
2 62220 Insertion, Replacement, Or Removal Of Extracranial Ventricular Shunt
2 62223 Insertion, Replacement, Or Removal Of Extracranial Ventricular Shunt
2 62225 Insertion, Replacement, Or Removal Of Extracranial Ventricular Shunt
2 62230 Insertion, Replacement, Or Removal Of Extracranial Ventricular Shunt
2 62252 Insertion, Replacement, Or Removal Of Extracranial Ventricular Shunt
Blue Cross NC Proprietary and Confidential 69 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
2 62256 Insertion, Replacement, Or Removal Of Extracranial Ventricular Shunt
2 62258 Insertion, Replacement, Or Removal Of Extracranial Ventricular Shunt
5 62263 Insertion Of Catheter Or Spinal Stimulator And Injection Into Spinal Canal
5 62264 Insertion Of Catheter Or Spinal Stimulator And Injection Into Spinal Canal
7 62267 Other Diagnostic Nervous System Procedures
9 62268 Other Or Therapeutic Nervous System Procedures
7 62269 Other Diagnostic Nervous System Procedures
4 62270 Diagnostic Spinal Tap
4 62272 Diagnostic Spinal Tap
8 62273 Other Non-Or Or Closed Therapeutic Nervous System Procedures
5 62280 Insertion Of Catheter Or Spinal Stimulator And Injection Into Spinal Canal
5 62281 Insertion Of Catheter Or Spinal Stimulator And Injection Into Spinal Canal
5 62282 Insertion Of Catheter Or Spinal Stimulator And Injection Into Spinal Canal
181 62284 Myelogram
3 62287 Laminectomy, Excision Intervertebral Disc
226 62290 Other Diagnostic Radiology And Related Techniques
226 62291 Other Diagnostic Radiology And Related Techniques
9 62292 Other Or Therapeutic Nervous System Procedures
9 62294 Other Or Therapeutic Nervous System Procedures
181 62302 Myelogram
181 62303 Myelogram
181 62304 Myelogram
181 62305 Myelogram
5 62320 Insertion Of Catheter Or Spinal Stimulator And Injection Into Spinal Canal
5 62321 Insertion Of Catheter Or Spinal Stimulator And Injection Into Spinal Canal
5 62322 Insertion Of Catheter Or Spinal Stimulator And Injection Into Spinal Canal
5 62323 Insertion Of Catheter Or Spinal Stimulator And Injection Into Spinal Canal
5 62324 Insertion Of Catheter Or Spinal Stimulator And Injection Into Spinal Canal
5 62325 Insertion Of Catheter Or Spinal Stimulator And Injection Into Spinal Canal
5 62326 Insertion Of Catheter Or Spinal Stimulator And Injection Into Spinal Canal
5 62327 Insertion Of Catheter Or Spinal Stimulator And Injection Into Spinal Canal
4 62328 Diagnostic Spinal Tap
8 62329 Other Non-Or Or Closed Therapeutic Nervous System Procedures
5 62350 Insertion Of Catheter Or Spinal Stimulator And Injection Into Spinal Canal
3 62351 Laminectomy, Excision Intervertebral Disc
5 62355 Insertion Of Catheter Or Spinal Stimulator And Injection Into Spinal Canal
9 62360 Other Or Therapeutic Nervous System Procedures
9 62361 Other Or Therapeutic Nervous System Procedures
9 62362 Other Or Therapeutic Nervous System Procedures
9 62365 Other Or Therapeutic Nervous System Procedures
175 62367 Other Or Therapeutic Procedures On Skin And Breast
175 62368 Other Or Therapeutic Procedures On Skin And Breast
8 62369 Other Non-Or Or Closed Therapeutic Nervous System Procedures
8 62370 Other Non-Or Or Closed Therapeutic Nervous System Procedures
3 62380 Laminectomy, Excision Intervertebral Disc
3 63001 Laminectomy, Excision Intervertebral Disc
3 63003 Laminectomy, Excision Intervertebral Disc
3 63005 Laminectomy, Excision Intervertebral Disc
3 63011 Laminectomy, Excision Intervertebral Disc
3 63012 Laminectomy, Excision Intervertebral Disc
3 63015 Laminectomy, Excision Intervertebral Disc
3 63016 Laminectomy, Excision Intervertebral Disc
3 63017 Laminectomy, Excision Intervertebral Disc
3 63020 Laminectomy, Excision Intervertebral Disc
3 63030 Laminectomy, Excision Intervertebral Disc
3 63035 Laminectomy, Excision Intervertebral Disc
3 63040 Laminectomy, Excision Intervertebral Disc
3 63042 Laminectomy, Excision Intervertebral Disc
3 63043 Laminectomy, Excision Intervertebral Disc
3 63044 Laminectomy, Excision Intervertebral Disc
3 63045 Laminectomy, Excision Intervertebral Disc
3 63046 Laminectomy, Excision Intervertebral Disc
3 63047 Laminectomy, Excision Intervertebral Disc
3 63048 Laminectomy, Excision Intervertebral Disc
3 63050 Laminectomy, Excision Intervertebral Disc
3 63051 Laminectomy, Excision Intervertebral Disc
3 63055 Laminectomy, Excision Intervertebral Disc
3 63056 Laminectomy, Excision Intervertebral Disc
3 63057 Laminectomy, Excision Intervertebral Disc
3 63064 Laminectomy, Excision Intervertebral Disc
3 63066 Laminectomy, Excision Intervertebral Disc
3 63075 Laminectomy, Excision Intervertebral Disc
3 63076 Laminectomy, Excision Intervertebral Disc
3 63077 Laminectomy, Excision Intervertebral Disc
Blue Cross NC Proprietary and Confidential 70 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
3 63078 Laminectomy, Excision Intervertebral Disc
3 63081 Laminectomy, Excision Intervertebral Disc
3 63082 Laminectomy, Excision Intervertebral Disc
3 63085 Laminectomy, Excision Intervertebral Disc
3 63086 Laminectomy, Excision Intervertebral Disc
3 63087 Laminectomy, Excision Intervertebral Disc
3 63088 Laminectomy, Excision Intervertebral Disc
3 63090 Laminectomy, Excision Intervertebral Disc
3 63091 Laminectomy, Excision Intervertebral Disc
3 63101 Laminectomy, Excision Intervertebral Disc
3 63102 Laminectomy, Excision Intervertebral Disc
3 63103 Laminectomy, Excision Intervertebral Disc
3 63170 Laminectomy, Excision Intervertebral Disc
3 63172 Laminectomy, Excision Intervertebral Disc
3 63173 Laminectomy, Excision Intervertebral Disc
3 63180 Laminectomy, Excision Intervertebral Disc
3 63182 Laminectomy, Excision Intervertebral Disc
3 63185 Laminectomy, Excision Intervertebral Disc
3 63190 Laminectomy, Excision Intervertebral Disc
3 63191 Laminectomy, Excision Intervertebral Disc
3 63194 Laminectomy, Excision Intervertebral Disc
3 63195 Laminectomy, Excision Intervertebral Disc
3 63196 Laminectomy, Excision Intervertebral Disc
3 63197 Laminectomy, Excision Intervertebral Disc
3 63198 Laminectomy, Excision Intervertebral Disc
3 63199 Laminectomy, Excision Intervertebral Disc
3 63200 Laminectomy, Excision Intervertebral Disc
3 63250 Laminectomy, Excision Intervertebral Disc
3 63251 Laminectomy, Excision Intervertebral Disc
3 63252 Laminectomy, Excision Intervertebral Disc
9 63265 Other Or Therapeutic Nervous System Procedures
9 63266 Other Or Therapeutic Nervous System Procedures
9 63267 Other Or Therapeutic Nervous System Procedures
9 63268 Other Or Therapeutic Nervous System Procedures
9 63270 Other Or Therapeutic Nervous System Procedures
9 63271 Other Or Therapeutic Nervous System Procedures
9 63272 Other Or Therapeutic Nervous System Procedures
9 63273 Other Or Therapeutic Nervous System Procedures
9 63275 Other Or Therapeutic Nervous System Procedures
9 63276 Other Or Therapeutic Nervous System Procedures
9 63277 Other Or Therapeutic Nervous System Procedures
9 63278 Other Or Therapeutic Nervous System Procedures
9 63280 Other Or Therapeutic Nervous System Procedures
9 63281 Other Or Therapeutic Nervous System Procedures
9 63282 Other Or Therapeutic Nervous System Procedures
9 63283 Other Or Therapeutic Nervous System Procedures
9 63285 Other Or Therapeutic Nervous System Procedures
9 63286 Other Or Therapeutic Nervous System Procedures
9 63287 Other Or Therapeutic Nervous System Procedures
9 63290 Other Or Therapeutic Nervous System Procedures
9 63295 Other Or Therapeutic Nervous System Procedures
9 63300 Other Or Therapeutic Nervous System Procedures
9 63301 Other Or Therapeutic Nervous System Procedures
9 63302 Other Or Therapeutic Nervous System Procedures
9 63303 Other Or Therapeutic Nervous System Procedures
9 63304 Other Or Therapeutic Nervous System Procedures
9 63305 Other Or Therapeutic Nervous System Procedures
9 63306 Other Or Therapeutic Nervous System Procedures
9 63307 Other Or Therapeutic Nervous System Procedures
9 63308 Other Or Therapeutic Nervous System Procedures
5 63600 Insertion Of Catheter Or Spinal Stimulator And Injection Into Spinal Canal
5 63610 Insertion Of Catheter Or Spinal Stimulator And Injection Into Spinal Canal
9 63620 Other Or Therapeutic Nervous System Procedures
9 63621 Other Or Therapeutic Nervous System Procedures
5 63650 Insertion Of Catheter Or Spinal Stimulator And Injection Into Spinal Canal
3 63655 Laminectomy, Excision Intervertebral Disc
5 63661 Insertion Of Catheter Or Spinal Stimulator And Injection Into Spinal Canal
5 63662 Insertion Of Catheter Or Spinal Stimulator And Injection Into Spinal Canal
5 63663 Insertion Of Catheter Or Spinal Stimulator And Injection Into Spinal Canal
5 63664 Insertion Of Catheter Or Spinal Stimulator And Injection Into Spinal Canal
5 63685 Insertion Of Catheter Or Spinal Stimulator And Injection Into Spinal Canal
5 63688 Insertion Of Catheter Or Spinal Stimulator And Injection Into Spinal Canal
9 63700 Other Or Therapeutic Nervous System Procedures
9 63702 Other Or Therapeutic Nervous System Procedures
Blue Cross NC Proprietary and Confidential 71 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
9 63704 Other Or Therapeutic Nervous System Procedures
9 63706 Other Or Therapeutic Nervous System Procedures
9 63707 Other Or Therapeutic Nervous System Procedures
3 63709 Laminectomy, Excision Intervertebral Disc
9 63710 Other Or Therapeutic Nervous System Procedures
3 63740 Laminectomy, Excision Intervertebral Disc
9 63741 Other Or Therapeutic Nervous System Procedures
9 63744 Other Or Therapeutic Nervous System Procedures
9 63746 Other Or Therapeutic Nervous System Procedures
8 64400 Other Non-Or Or Closed Therapeutic Nervous System Procedures
8 64405 Other Non-Or Or Closed Therapeutic Nervous System Procedures
9 64408 Other Or Therapeutic Nervous System Procedures
8 64415 Other Non-Or Or Closed Therapeutic Nervous System Procedures
5 64416 Insertion Of Catheter Or Spinal Stimulator And Injection Into Spinal Canal
8 64417 Other Non-Or Or Closed Therapeutic Nervous System Procedures
8 64418 Other Non-Or Or Closed Therapeutic Nervous System Procedures
8 64420 Other Non-Or Or Closed Therapeutic Nervous System Procedures
8 64421 Other Non-Or Or Closed Therapeutic Nervous System Procedures
8 64425 Other Non-Or Or Closed Therapeutic Nervous System Procedures
8 64430 Other Non-Or Or Closed Therapeutic Nervous System Procedures
8 64435 Other Non-Or Or Closed Therapeutic Nervous System Procedures
8 64445 Other Non-Or Or Closed Therapeutic Nervous System Procedures
5 64446 Insertion Of Catheter Or Spinal Stimulator And Injection Into Spinal Canal
8 64447 Other Non-Or Or Closed Therapeutic Nervous System Procedures
5 64448 Insertion Of Catheter Or Spinal Stimulator And Injection Into Spinal Canal
5 64449 Insertion Of Catheter Or Spinal Stimulator And Injection Into Spinal Canal
8 64450 Other Non-Or Or Closed Therapeutic Nervous System Procedures
156 64451 Injections And Aspirations Of Muscles, Tendons, Bursa, Joints And Soft Tissue
156 64454 Injections And Aspirations Of Muscles, Tendons, Bursa, Joints And Soft Tissue
8 64455 Other Non-Or Or Closed Therapeutic Nervous System Procedures
5 64461 Insertion Of Catheter Or Spinal Stimulator And Injection Into Spinal Canal
5 64462 Insertion Of Catheter Or Spinal Stimulator And Injection Into Spinal Canal
5 64463 Insertion Of Catheter Or Spinal Stimulator And Injection Into Spinal Canal
5 64479 Insertion Of Catheter Or Spinal Stimulator And Injection Into Spinal Canal
5 64480 Insertion Of Catheter Or Spinal Stimulator And Injection Into Spinal Canal
5 64483 Insertion Of Catheter Or Spinal Stimulator And Injection Into Spinal Canal
5 64484 Insertion Of Catheter Or Spinal Stimulator And Injection Into Spinal Canal
8 64486 Other Non-Or Or Closed Therapeutic Nervous System Procedures
8 64487 Other Non-Or Or Closed Therapeutic Nervous System Procedures
8 64488 Other Non-Or Or Closed Therapeutic Nervous System Procedures
8 64489 Other Non-Or Or Closed Therapeutic Nervous System Procedures
8 64490 Other Non-Or Or Closed Therapeutic Nervous System Procedures
8 64491 Other Non-Or Or Closed Therapeutic Nervous System Procedures
8 64492 Other Non-Or Or Closed Therapeutic Nervous System Procedures
8 64493 Other Non-Or Or Closed Therapeutic Nervous System Procedures
8 64494 Other Non-Or Or Closed Therapeutic Nervous System Procedures
8 64495 Other Non-Or Or Closed Therapeutic Nervous System Procedures
8 64505 Other Non-Or Or Closed Therapeutic Nervous System Procedures
8 64510 Other Non-Or Or Closed Therapeutic Nervous System Procedures
8 64517 Other Non-Or Or Closed Therapeutic Nervous System Procedures
8 64520 Other Non-Or Or Closed Therapeutic Nervous System Procedures
8 64530 Other Non-Or Or Closed Therapeutic Nervous System Procedures
9 64553 Other Or Therapeutic Nervous System Procedures
9 64555 Other Or Therapeutic Nervous System Procedures
9 64561 Other Or Therapeutic Nervous System Procedures
9 64566 Other Or Therapeutic Nervous System Procedures
9 64568 Other Or Therapeutic Nervous System Procedures
9 64569 Other Or Therapeutic Nervous System Procedures
9 64570 Other Or Therapeutic Nervous System Procedures
9 64575 Other Or Therapeutic Nervous System Procedures
9 64580 Other Or Therapeutic Nervous System Procedures
9 64581 Other Or Therapeutic Nervous System Procedures
9 64585 Other Or Therapeutic Nervous System Procedures
9 64590 Other Or Therapeutic Nervous System Procedures
9 64595 Other Or Therapeutic Nervous System Procedures
9 64600 Other Or Therapeutic Nervous System Procedures
9 64605 Other Or Therapeutic Nervous System Procedures
9 64610 Other Or Therapeutic Nervous System Procedures
9 64611 Other Or Therapeutic Nervous System Procedures
9 64612 Other Or Therapeutic Nervous System Procedures
9 64615 Other Or Therapeutic Nervous System Procedures
9 64616 Other Or Therapeutic Nervous System Procedures
9 64617 Other Or Therapeutic Nervous System Procedures
9 64620 Other Or Therapeutic Nervous System Procedures
Blue Cross NC Proprietary and Confidential 72 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
156 64624 Injections And Aspirations Of Muscles, Tendons, Bursa, Joints And Soft Tissue
9 64625 Other Or Therapeutic Nervous System Procedures
9 64630 Other Or Therapeutic Nervous System Procedures
9 64632 Other Or Therapeutic Nervous System Procedures
9 64633 Other Or Therapeutic Nervous System Procedures
9 64634 Other Or Therapeutic Nervous System Procedures
9 64635 Other Or Therapeutic Nervous System Procedures
9 64636 Other Or Therapeutic Nervous System Procedures
9 64640 Other Or Therapeutic Nervous System Procedures
9 64642 Other Or Therapeutic Nervous System Procedures
9 64643 Other Or Therapeutic Nervous System Procedures
9 64644 Other Or Therapeutic Nervous System Procedures
9 64645 Other Or Therapeutic Nervous System Procedures
9 64646 Other Or Therapeutic Nervous System Procedures
9 64647 Other Or Therapeutic Nervous System Procedures
156 64650 Injections And Aspirations Of Muscles, Tendons, Bursa, Joints And Soft Tissue
156 64653 Injections And Aspirations Of Muscles, Tendons, Bursa, Joints And Soft Tissue
8 64680 Other Non-Or Or Closed Therapeutic Nervous System Procedures
8 64681 Other Non-Or Or Closed Therapeutic Nervous System Procedures
6 64702 Decompression Peripheral Nerve
6 64704 Decompression Peripheral Nerve
6 64708 Decompression Peripheral Nerve
6 64712 Decompression Peripheral Nerve
6 64713 Decompression Peripheral Nerve
6 64714 Decompression Peripheral Nerve
6 64716 Decompression Peripheral Nerve
6 64718 Decompression Peripheral Nerve
6 64719 Decompression Peripheral Nerve
6 64721 Decompression Peripheral Nerve
6 64722 Decompression Peripheral Nerve
6 64726 Decompression Peripheral Nerve
6 64727 Decompression Peripheral Nerve
9 64732 Other Or Therapeutic Nervous System Procedures
9 64734 Other Or Therapeutic Nervous System Procedures
9 64736 Other Or Therapeutic Nervous System Procedures
9 64738 Other Or Therapeutic Nervous System Procedures
9 64740 Other Or Therapeutic Nervous System Procedures
9 64742 Other Or Therapeutic Nervous System Procedures
9 64744 Other Or Therapeutic Nervous System Procedures
9 64746 Other Or Therapeutic Nervous System Procedures
9 64755 Other Or Therapeutic Nervous System Procedures
9 64760 Other Or Therapeutic Nervous System Procedures
9 64763 Other Or Therapeutic Nervous System Procedures
9 64766 Other Or Therapeutic Nervous System Procedures
9 64771 Other Or Therapeutic Nervous System Procedures
9 64772 Other Or Therapeutic Nervous System Procedures
9 64774 Other Or Therapeutic Nervous System Procedures
9 64776 Other Or Therapeutic Nervous System Procedures
9 64778 Other Or Therapeutic Nervous System Procedures
9 64782 Other Or Therapeutic Nervous System Procedures
9 64783 Other Or Therapeutic Nervous System Procedures
9 64784 Other Or Therapeutic Nervous System Procedures
9 64786 Other Or Therapeutic Nervous System Procedures
9 64787 Other Or Therapeutic Nervous System Procedures
9 64788 Other Or Therapeutic Nervous System Procedures
9 64790 Other Or Therapeutic Nervous System Procedures
9 64792 Other Or Therapeutic Nervous System Procedures
7 64795 Other Diagnostic Nervous System Procedures
9 64802 Other Or Therapeutic Nervous System Procedures
9 64804 Other Or Therapeutic Nervous System Procedures
9 64809 Other Or Therapeutic Nervous System Procedures
9 64818 Other Or Therapeutic Nervous System Procedures
9 64820 Other Or Therapeutic Nervous System Procedures
9 64821 Other Or Therapeutic Nervous System Procedures
9 64822 Other Or Therapeutic Nervous System Procedures
9 64823 Other Or Therapeutic Nervous System Procedures
9 64831 Other Or Therapeutic Nervous System Procedures
9 64832 Other Or Therapeutic Nervous System Procedures
9 64834 Other Or Therapeutic Nervous System Procedures
9 64835 Other Or Therapeutic Nervous System Procedures
9 64836 Other Or Therapeutic Nervous System Procedures
9 64837 Other Or Therapeutic Nervous System Procedures
9 64840 Other Or Therapeutic Nervous System Procedures
9 64856 Other Or Therapeutic Nervous System Procedures
Blue Cross NC Proprietary and Confidential 73 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
9 64857 Other Or Therapeutic Nervous System Procedures
9 64858 Other Or Therapeutic Nervous System Procedures
9 64859 Other Or Therapeutic Nervous System Procedures
9 64861 Other Or Therapeutic Nervous System Procedures
9 64862 Other Or Therapeutic Nervous System Procedures
9 64864 Other Or Therapeutic Nervous System Procedures
9 64865 Other Or Therapeutic Nervous System Procedures
9 64866 Other Or Therapeutic Nervous System Procedures
9 64868 Other Or Therapeutic Nervous System Procedures
9 64872 Other Or Therapeutic Nervous System Procedures
9 64874 Other Or Therapeutic Nervous System Procedures
9 64876 Other Or Therapeutic Nervous System Procedures
9 64885 Other Or Therapeutic Nervous System Procedures
9 64886 Other Or Therapeutic Nervous System Procedures
9 64890 Other Or Therapeutic Nervous System Procedures
9 64891 Other Or Therapeutic Nervous System Procedures
9 64892 Other Or Therapeutic Nervous System Procedures
9 64893 Other Or Therapeutic Nervous System Procedures
9 64895 Other Or Therapeutic Nervous System Procedures
9 64896 Other Or Therapeutic Nervous System Procedures
9 64897 Other Or Therapeutic Nervous System Procedures
9 64898 Other Or Therapeutic Nervous System Procedures
9 64901 Other Or Therapeutic Nervous System Procedures
9 64902 Other Or Therapeutic Nervous System Procedures
9 64905 Other Or Therapeutic Nervous System Procedures
9 64907 Other Or Therapeutic Nervous System Procedures
9 64910 Other Or Therapeutic Nervous System Procedures
9 64911 Other Or Therapeutic Nervous System Procedures
9 64912 Other Or Therapeutic Nervous System Procedures
9 64913 Other Or Therapeutic Nervous System Procedures
9 64999 Other Or Therapeutic Nervous System Procedures
21 65091 Other Extraocular Muscle And Orbit Therapeutic Procedures
21 65093 Other Extraocular Muscle And Orbit Therapeutic Procedures
21 65101 Other Extraocular Muscle And Orbit Therapeutic Procedures
21 65103 Other Extraocular Muscle And Orbit Therapeutic Procedures
21 65105 Other Extraocular Muscle And Orbit Therapeutic Procedures
21 65110 Other Extraocular Muscle And Orbit Therapeutic Procedures
21 65112 Other Extraocular Muscle And Orbit Therapeutic Procedures
21 65114 Other Extraocular Muscle And Orbit Therapeutic Procedures
21 65125 Other Extraocular Muscle And Orbit Therapeutic Procedures
21 65130 Other Extraocular Muscle And Orbit Therapeutic Procedures
21 65135 Other Extraocular Muscle And Orbit Therapeutic Procedures
21 65140 Other Extraocular Muscle And Orbit Therapeutic Procedures
21 65150 Other Extraocular Muscle And Orbit Therapeutic Procedures
21 65155 Other Extraocular Muscle And Orbit Therapeutic Procedures
21 65175 Other Extraocular Muscle And Orbit Therapeutic Procedures
229 65205 Nonoperative Removal Of Foreign Body
220 65210 Ophthalmologic And Otologic Diagnosis And Treatment
229 65220 Nonoperative Removal Of Foreign Body
229 65222 Nonoperative Removal Of Foreign Body
229 65235 Nonoperative Removal Of Foreign Body
229 65260 Nonoperative Removal Of Foreign Body
20 65265 Other Intraocular Therapeutic Procedures
220 65270 Ophthalmologic And Otologic Diagnosis And Treatment
220 65272 Ophthalmologic And Otologic Diagnosis And Treatment
220 65273 Ophthalmologic And Otologic Diagnosis And Treatment
220 65275 Ophthalmologic And Otologic Diagnosis And Treatment
220 65280 Ophthalmologic And Otologic Diagnosis And Treatment
220 65285 Ophthalmologic And Otologic Diagnosis And Treatment
220 65286 Ophthalmologic And Otologic Diagnosis And Treatment
21 65290 Other Extraocular Muscle And Orbit Therapeutic Procedures
220 65400 Ophthalmologic And Otologic Diagnosis And Treatment
220 65410 Ophthalmologic And Otologic Diagnosis And Treatment
220 65420 Ophthalmologic And Otologic Diagnosis And Treatment
220 65426 Ophthalmologic And Otologic Diagnosis And Treatment
220 65430 Ophthalmologic And Otologic Diagnosis And Treatment
220 65435 Ophthalmologic And Otologic Diagnosis And Treatment
220 65436 Ophthalmologic And Otologic Diagnosis And Treatment
220 65450 Ophthalmologic And Otologic Diagnosis And Treatment
220 65600 Ophthalmologic And Otologic Diagnosis And Treatment
13 65710 Eye Procedure - Corneal Transplant
13 65730 Eye Procedure - Corneal Transplant
13 65750 Eye Procedure - Corneal Transplant
13 65755 Eye Procedure - Corneal Transplant
Blue Cross NC Proprietary and Confidential 74 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
13 65756 Eye Procedure - Corneal Transplant
13 65757 Eye Procedure - Corneal Transplant
19 65760 Ophthalmologic And Otologic Diagnosis And Treatment
19 65765 Ophthalmologic And Otologic Diagnosis And Treatment
19 65767 Ophthalmologic And Otologic Diagnosis And Treatment
19 65770 Ophthalmologic And Otologic Diagnosis And Treatment
220 65771 Ophthalmologic And Otologic Diagnosis And Treatment
220 65772 Ophthalmologic And Otologic Diagnosis And Treatment
220 65775 Ophthalmologic And Otologic Diagnosis And Treatment
220 65778 Ophthalmologic And Otologic Diagnosis And Treatment
220 65779 Ophthalmologic And Otologic Diagnosis And Treatment
176 65780 Other Organ Transplantation
176 65781 Other Organ Transplantation
176 65782 Other Organ Transplantation
19 65785 Ophthalmologic And Otologic Diagnosis And Treatment
18 65800 Diagnostic Procedures On Eye
20 65810 Other Intraocular Therapeutic Procedures
20 65815 Other Intraocular Therapeutic Procedures
14 65820 Glaucoma Procedures
14 65850 Glaucoma Procedures
14 65855 Glaucoma Procedures
20 65860 Other Intraocular Therapeutic Procedures
20 65865 Other Intraocular Therapeutic Procedures
20 65870 Other Intraocular Therapeutic Procedures
20 65875 Other Intraocular Therapeutic Procedures
20 65880 Other Intraocular Therapeutic Procedures
20 65900 Other Intraocular Therapeutic Procedures
20 65920 Other Intraocular Therapeutic Procedures
20 65930 Other Intraocular Therapeutic Procedures
20 66020 Other Intraocular Therapeutic Procedures
20 66030 Other Intraocular Therapeutic Procedures
20 66130 Other Intraocular Therapeutic Procedures
14 66150 Glaucoma Procedures
14 66155 Glaucoma Procedures
14 66160 Glaucoma Procedures
14 66170 Glaucoma Procedures
14 66172 Glaucoma Procedures
14 66174 Glaucoma Procedures
14 66175 Glaucoma Procedures
14 66179 Glaucoma Procedures
14 66180 Glaucoma Procedures
14 66183 Glaucoma Procedures
14 66184 Glaucoma Procedures
14 66185 Glaucoma Procedures
20 66225 Other Intraocular Therapeutic Procedures
19 66250 Ophthalmologic And Otologic Diagnosis And Treatment
20 66500 Other Intraocular Therapeutic Procedures
20 66505 Other Intraocular Therapeutic Procedures
20 66600 Other Intraocular Therapeutic Procedures
20 66605 Other Intraocular Therapeutic Procedures
20 66625 Other Intraocular Therapeutic Procedures
20 66630 Other Intraocular Therapeutic Procedures
20 66635 Other Intraocular Therapeutic Procedures
20 66680 Other Intraocular Therapeutic Procedures
20 66682 Other Intraocular Therapeutic Procedures
14 66700 Glaucoma Procedures
14 66710 Glaucoma Procedures
14 66711 Glaucoma Procedures
14 66720 Glaucoma Procedures
14 66740 Glaucoma Procedures
14 66761 Glaucoma Procedures
20 66762 Other Intraocular Therapeutic Procedures
20 66770 Other Intraocular Therapeutic Procedures
15 66820 Lens And Cataract Procedures
15 66821 Lens And Cataract Procedures
15 66825 Lens And Cataract Procedures
15 66830 Lens And Cataract Procedures
15 66840 Lens And Cataract Procedures
15 66850 Lens And Cataract Procedures
15 66852 Lens And Cataract Procedures
15 66920 Lens And Cataract Procedures
15 66930 Lens And Cataract Procedures
15 66940 Lens And Cataract Procedures
15 66982 Lens And Cataract Procedures
Blue Cross NC Proprietary and Confidential 75 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
15 66983 Lens And Cataract Procedures
15 66984 Lens And Cataract Procedures
15 66985 Lens And Cataract Procedures
15 66986 Lens And Cataract Procedures
15 66987 Lens And Cataract Procedures
15 66988 Lens And Cataract Procedures
20 66990 Other Intraocular Therapeutic Procedures
20 66999 Other Intraocular Therapeutic Procedures
20 67005 Other Intraocular Therapeutic Procedures
20 67010 Other Intraocular Therapeutic Procedures
20 67015 Other Intraocular Therapeutic Procedures
20 67025 Other Intraocular Therapeutic Procedures
20 67027 Other Intraocular Therapeutic Procedures
20 67028 Other Intraocular Therapeutic Procedures
20 67030 Other Intraocular Therapeutic Procedures
20 67031 Other Intraocular Therapeutic Procedures
20 67036 Other Intraocular Therapeutic Procedures
16 67039 Repair Of Retinal Tear, Detachment
16 67040 Repair Of Retinal Tear, Detachment
20 67041 Other Intraocular Therapeutic Procedures
20 67042 Other Intraocular Therapeutic Procedures
20 67043 Other Intraocular Therapeutic Procedures
16 67101 Repair Of Retinal Tear, Detachment
16 67105 Repair Of Retinal Tear, Detachment
16 67107 Repair Of Retinal Tear, Detachment
16 67108 Repair Of Retinal Tear, Detachment
16 67110 Repair Of Retinal Tear, Detachment
16 67113 Repair Of Retinal Tear, Detachment
20 67115 Other Intraocular Therapeutic Procedures
20 67120 Other Intraocular Therapeutic Procedures
20 67121 Other Intraocular Therapeutic Procedures
16 67141 Repair Of Retinal Tear, Detachment
16 67145 Repair Of Retinal Tear, Detachment
17 67208 Destruction Of Lesion Of Retina And Choroid
17 67210 Destruction Of Lesion Of Retina And Choroid
17 67218 Destruction Of Lesion Of Retina And Choroid
17 67220 Destruction Of Lesion Of Retina And Choroid
17 67221 Destruction Of Lesion Of Retina And Choroid
17 67225 Destruction Of Lesion Of Retina And Choroid
17 67227 Destruction Of Lesion Of Retina And Choroid
17 67228 Destruction Of Lesion Of Retina And Choroid
17 67229 Destruction Of Lesion Of Retina And Choroid
20 67250 Other Intraocular Therapeutic Procedures
20 67255 Other Intraocular Therapeutic Procedures
20 67299 Other Intraocular Therapeutic Procedures
21 67311 Other Extraocular Muscle And Orbit Therapeutic Procedures
21 67312 Other Extraocular Muscle And Orbit Therapeutic Procedures
21 67314 Other Extraocular Muscle And Orbit Therapeutic Procedures
21 67316 Other Extraocular Muscle And Orbit Therapeutic Procedures
21 67318 Other Extraocular Muscle And Orbit Therapeutic Procedures
21 67320 Other Extraocular Muscle And Orbit Therapeutic Procedures
21 67331 Other Extraocular Muscle And Orbit Therapeutic Procedures
21 67332 Other Extraocular Muscle And Orbit Therapeutic Procedures
21 67334 Other Extraocular Muscle And Orbit Therapeutic Procedures
21 67335 Other Extraocular Muscle And Orbit Therapeutic Procedures
21 67340 Other Extraocular Muscle And Orbit Therapeutic Procedures
21 67343 Other Extraocular Muscle And Orbit Therapeutic Procedures
21 67345 Other Extraocular Muscle And Orbit Therapeutic Procedures
18 67346 Diagnostic Procedures On Eye
21 67399 Other Extraocular Muscle And Orbit Therapeutic Procedures
18 67400 Diagnostic Procedures On Eye
21 67405 Other Extraocular Muscle And Orbit Therapeutic Procedures
21 67412 Other Extraocular Muscle And Orbit Therapeutic Procedures
21 67413 Other Extraocular Muscle And Orbit Therapeutic Procedures
21 67414 Other Extraocular Muscle And Orbit Therapeutic Procedures
18 67415 Diagnostic Procedures On Eye
21 67420 Other Extraocular Muscle And Orbit Therapeutic Procedures
21 67430 Other Extraocular Muscle And Orbit Therapeutic Procedures
21 67440 Other Extraocular Muscle And Orbit Therapeutic Procedures
21 67445 Other Extraocular Muscle And Orbit Therapeutic Procedures
18 67450 Diagnostic Procedures On Eye
21 67500 Other Extraocular Muscle And Orbit Therapeutic Procedures
21 67505 Other Extraocular Muscle And Orbit Therapeutic Procedures
21 67515 Other Extraocular Muscle And Orbit Therapeutic Procedures
Blue Cross NC Proprietary and Confidential 76 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
21 67550 Other Extraocular Muscle And Orbit Therapeutic Procedures
21 67560 Other Extraocular Muscle And Orbit Therapeutic Procedures
9 67570 Other Or Therapeutic Nervous System Procedures
21 67599 Other Extraocular Muscle And Orbit Therapeutic Procedures
19 67700 Ophthalmologic And Otologic Diagnosis And Treatment
19 67710 Ophthalmologic And Otologic Diagnosis And Treatment
19 67715 Ophthalmologic And Otologic Diagnosis And Treatment
19 67800 Ophthalmologic And Otologic Diagnosis And Treatment
19 67801 Ophthalmologic And Otologic Diagnosis And Treatment
19 67805 Ophthalmologic And Otologic Diagnosis And Treatment
19 67808 Ophthalmologic And Otologic Diagnosis And Treatment
18 67810 Diagnostic Procedures On Eye
19 67820 Ophthalmologic And Otologic Diagnosis And Treatment
19 67825 Ophthalmologic And Otologic Diagnosis And Treatment
19 67830 Ophthalmologic And Otologic Diagnosis And Treatment
19 67835 Ophthalmologic And Otologic Diagnosis And Treatment
19 67840 Ophthalmologic And Otologic Diagnosis And Treatment
19 67850 Ophthalmologic And Otologic Diagnosis And Treatment
19 67875 Ophthalmologic And Otologic Diagnosis And Treatment
19 67880 Ophthalmologic And Otologic Diagnosis And Treatment
19 67882 Ophthalmologic And Otologic Diagnosis And Treatment
19 67900 Ophthalmologic And Otologic Diagnosis And Treatment
19 67901 Ophthalmologic And Otologic Diagnosis And Treatment
19 67902 Ophthalmologic And Otologic Diagnosis And Treatment
19 67903 Ophthalmologic And Otologic Diagnosis And Treatment
19 67904 Ophthalmologic And Otologic Diagnosis And Treatment
19 67906 Ophthalmologic And Otologic Diagnosis And Treatment
19 67908 Ophthalmologic And Otologic Diagnosis And Treatment
19 67909 Ophthalmologic And Otologic Diagnosis And Treatment
19 67911 Ophthalmologic And Otologic Diagnosis And Treatment
19 67912 Ophthalmologic And Otologic Diagnosis And Treatment
19 67914 Ophthalmologic And Otologic Diagnosis And Treatment
19 67915 Ophthalmologic And Otologic Diagnosis And Treatment
19 67916 Ophthalmologic And Otologic Diagnosis And Treatment
19 67917 Ophthalmologic And Otologic Diagnosis And Treatment
19 67921 Ophthalmologic And Otologic Diagnosis And Treatment
19 67922 Ophthalmologic And Otologic Diagnosis And Treatment
19 67923 Ophthalmologic And Otologic Diagnosis And Treatment
19 67924 Ophthalmologic And Otologic Diagnosis And Treatment
19 67930 Ophthalmologic And Otologic Diagnosis And Treatment
19 67935 Ophthalmologic And Otologic Diagnosis And Treatment
19 67938 Ophthalmologic And Otologic Diagnosis And Treatment
19 67950 Ophthalmologic And Otologic Diagnosis And Treatment
19 67961 Ophthalmologic And Otologic Diagnosis And Treatment
19 67966 Ophthalmologic And Otologic Diagnosis And Treatment
19 67971 Ophthalmologic And Otologic Diagnosis And Treatment
19 67973 Ophthalmologic And Otologic Diagnosis And Treatment
19 67974 Ophthalmologic And Otologic Diagnosis And Treatment
19 67975 Ophthalmologic And Otologic Diagnosis And Treatment
19 67999 Ophthalmologic And Otologic Diagnosis And Treatment
19 68020 Ophthalmologic And Otologic Diagnosis And Treatment
19 68040 Ophthalmologic And Otologic Diagnosis And Treatment
18 68100 Diagnostic Procedures On Eye
19 68110 Ophthalmologic And Otologic Diagnosis And Treatment
19 68115 Ophthalmologic And Otologic Diagnosis And Treatment
19 68130 Ophthalmologic And Otologic Diagnosis And Treatment
19 68135 Ophthalmologic And Otologic Diagnosis And Treatment
19 68200 Ophthalmologic And Otologic Diagnosis And Treatment
19 68320 Ophthalmologic And Otologic Diagnosis And Treatment
19 68325 Ophthalmologic And Otologic Diagnosis And Treatment
19 68326 Ophthalmologic And Otologic Diagnosis And Treatment
19 68328 Ophthalmologic And Otologic Diagnosis And Treatment
19 68330 Ophthalmologic And Otologic Diagnosis And Treatment
19 68335 Ophthalmologic And Otologic Diagnosis And Treatment
19 68340 Ophthalmologic And Otologic Diagnosis And Treatment
19 68360 Ophthalmologic And Otologic Diagnosis And Treatment
19 68362 Ophthalmologic And Otologic Diagnosis And Treatment
19 68371 Ophthalmologic And Otologic Diagnosis And Treatment
19 68399 Ophthalmologic And Otologic Diagnosis And Treatment
19 68400 Ophthalmologic And Otologic Diagnosis And Treatment
19 68420 Ophthalmologic And Otologic Diagnosis And Treatment
19 68440 Ophthalmologic And Otologic Diagnosis And Treatment
19 68500 Ophthalmologic And Otologic Diagnosis And Treatment
19 68505 Ophthalmologic And Otologic Diagnosis And Treatment
Blue Cross NC Proprietary and Confidential 77 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
18 68510 Diagnostic Procedures On Eye
19 68520 Ophthalmologic And Otologic Diagnosis And Treatment
18 68525 Diagnostic Procedures On Eye
19 68530 Ophthalmologic And Otologic Diagnosis And Treatment
19 68540 Ophthalmologic And Otologic Diagnosis And Treatment
19 68550 Ophthalmologic And Otologic Diagnosis And Treatment
19 68700 Ophthalmologic And Otologic Diagnosis And Treatment
19 68705 Ophthalmologic And Otologic Diagnosis And Treatment
19 68720 Ophthalmologic And Otologic Diagnosis And Treatment
19 68745 Ophthalmologic And Otologic Diagnosis And Treatment
19 68750 Ophthalmologic And Otologic Diagnosis And Treatment
19 68760 Ophthalmologic And Otologic Diagnosis And Treatment
19 68761 Ophthalmologic And Otologic Diagnosis And Treatment
19 68770 Ophthalmologic And Otologic Diagnosis And Treatment
19 68801 Ophthalmologic And Otologic Diagnosis And Treatment
19 68810 Ophthalmologic And Otologic Diagnosis And Treatment
19 68811 Ophthalmologic And Otologic Diagnosis And Treatment
19 68815 Ophthalmologic And Otologic Diagnosis And Treatment
19 68816 Ophthalmologic And Otologic Diagnosis And Treatment
19 68840 Ophthalmologic And Otologic Diagnosis And Treatment
226 68850 Other Diagnostic Radiology And Related Techniques
21 68899 Other Extraocular Muscle And Orbit Therapeutic Procedures
26 69000 Other Therapeutic Ear Procedures
26 69005 Other Therapeutic Ear Procedures
26 69020 Other Therapeutic Ear Procedures
26 69090 Other Therapeutic Ear Procedures
25 69100 Diagnostic Procedures On Ear
25 69105 Diagnostic Procedures On Ear
26 69110 Other Therapeutic Ear Procedures
26 69120 Other Therapeutic Ear Procedures
26 69140 Other Therapeutic Ear Procedures
26 69145 Other Therapeutic Ear Procedures
26 69150 Other Therapeutic Ear Procedures
26 69155 Other Therapeutic Ear Procedures
229 69200 Nonoperative Removal Of Foreign Body
26 69205 Other Therapeutic Ear Procedures
26 69209 Other Therapeutic Ear Procedures
26 69210 Other Therapeutic Ear Procedures
169 69220 Debridement Of Wound, Infection Or Burn
169 69222 Debridement Of Wound, Infection Or Burn
26 69300 Other Therapeutic Ear Procedures
26 69310 Other Therapeutic Ear Procedures
26 69320 Other Therapeutic Ear Procedures
26 69399 Other Therapeutic Ear Procedures
23 69420 Myringotomy
23 69421 Myringotomy
26 69424 Other Therapeutic Ear Procedures
22 69433 Tympanoplasty
22 69436 Tympanoplasty
23 69440 Myringotomy
22 69450 Tympanoplasty
24 69501 Mastoidectomy
24 69502 Mastoidectomy
24 69505 Mastoidectomy
24 69511 Mastoidectomy
24 69530 Mastoidectomy
26 69535 Other Therapeutic Ear Procedures
26 69540 Other Therapeutic Ear Procedures
26 69550 Other Therapeutic Ear Procedures
26 69552 Other Therapeutic Ear Procedures
26 69554 Other Therapeutic Ear Procedures
24 69601 Mastoidectomy
24 69602 Mastoidectomy
24 69603 Mastoidectomy
22 69604 Tympanoplasty
24 69605 Mastoidectomy
22 69610 Tympanoplasty
22 69620 Tympanoplasty
22 69631 Tympanoplasty
22 69632 Tympanoplasty
22 69633 Tympanoplasty
22 69635 Tympanoplasty
22 69636 Tympanoplasty
22 69637 Tympanoplasty
Blue Cross NC Proprietary and Confidential 78 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
24 69641 Mastoidectomy
24 69642 Mastoidectomy
24 69643 Mastoidectomy
24 69644 Mastoidectomy
24 69645 Mastoidectomy
24 69646 Mastoidectomy
26 69650 Other Therapeutic Ear Procedures
26 69660 Other Therapeutic Ear Procedures
26 69661 Other Therapeutic Ear Procedures
26 69662 Other Therapeutic Ear Procedures
26 69666 Other Therapeutic Ear Procedures
26 69667 Other Therapeutic Ear Procedures
26 69670 Other Therapeutic Ear Procedures
26 69676 Other Therapeutic Ear Procedures
26 69700 Other Therapeutic Ear Procedures
26 69710 Other Therapeutic Ear Procedures
26 69711 Other Therapeutic Ear Procedures
26 69714 Other Therapeutic Ear Procedures
26 69715 Other Therapeutic Ear Procedures
26 69717 Other Therapeutic Ear Procedures
26 69718 Other Therapeutic Ear Procedures
9 69720 Other Or Therapeutic Nervous System Procedures
9 69725 Other Or Therapeutic Nervous System Procedures
9 69740 Other Or Therapeutic Nervous System Procedures
9 69745 Other Or Therapeutic Nervous System Procedures
26 69799 Other Therapeutic Ear Procedures
26 69801 Other Therapeutic Ear Procedures
26 69805 Other Therapeutic Ear Procedures
26 69806 Other Therapeutic Ear Procedures
26 69905 Other Therapeutic Ear Procedures
24 69910 Mastoidectomy
26 69915 Other Therapeutic Ear Procedures
26 69930 Other Therapeutic Ear Procedures
26 69949 Other Therapeutic Ear Procedures
26 69950 Other Therapeutic Ear Procedures
9 69955 Other Or Therapeutic Nervous System Procedures
26 69960 Other Therapeutic Ear Procedures
142 69970 Partial Excision Bone
26 69979 Other Therapeutic Ear Procedures
231 69990 Other Therapeutic Procedures
181 70010 Myelogram
209 70015 Radioisotope Scan And Function Studies
220 70030 Ophthalmologic And Otologic Diagnosis And Treatment
I1B 70100 Other Diagnostic Radiology And Related Techniques
I1B 70110 Other Diagnostic Radiology And Related Techniques
I1B 70120 Other Diagnostic Radiology And Related Techniques
I1B 70130 Other Diagnostic Radiology And Related Techniques
I1B 70134 Other Diagnostic Radiology And Related Techniques
I1B 70140 Other Diagnostic Radiology And Related Techniques
I1B 70150 Other Diagnostic Radiology And Related Techniques
I1B 70160 Other Diagnostic Radiology And Related Techniques
226 70170 Other Diagnostic Radiology And Related Techniques
I1B 70190 Other Diagnostic Radiology And Related Techniques
I1B 70200 Other Diagnostic Radiology And Related Techniques
I1B 70210 Other Diagnostic Radiology And Related Techniques
I1B 70220 Other Diagnostic Radiology And Related Techniques
I1B 70240 Other Diagnostic Radiology And Related Techniques
I1B 70250 Other Diagnostic Radiology And Related Techniques
I1B 70260 Other Diagnostic Radiology And Related Techniques
I1B 70300 Other Diagnostic Radiology And Related Techniques
I1B 70310 Other Diagnostic Radiology And Related Techniques
I1B 70320 Other Diagnostic Radiology And Related Techniques
I1B 70328 Other Diagnostic Radiology And Related Techniques
I1B 70330 Other Diagnostic Radiology And Related Techniques
I1B 70332 Other Diagnostic Radiology And Related Techniques
I2D 70336 Advanced Imaging - MRI, Other
I1B 70350 Other Diagnostic Radiology And Related Techniques
I1B 70355 Other Diagnostic Radiology And Related Techniques
226 70360 Other Diagnostic Radiology And Related Techniques
226 70370 Other Diagnostic Radiology And Related Techniques
226 70371 Other Diagnostic Radiology And Related Techniques
226 70380 Other Diagnostic Radiology And Related Techniques
226 70390 Other Diagnostic Radiology And Related Techniques
177 70450 Computerized Axial Tomography (CT) Scan Head
Blue Cross NC Proprietary and Confidential 79 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
177 70460 Computerized Axial Tomography (CT) Scan Head
177 70470 Computerized Axial Tomography (CT) Scan Head
177 70480 Computerized Axial Tomography (CT) Scan Head
177 70481 Computerized Axial Tomography (CT) Scan Head
177 70482 Computerized Axial Tomography (CT) Scan Head
177 70486 Computerized Axial Tomography (CT) Scan Head
177 70487 Computerized Axial Tomography (CT) Scan Head
177 70488 Computerized Axial Tomography (CT) Scan Head
180 70490 Other CT Scan
180 70491 Other CT Scan
180 70492 Other CT Scan
177 70496 Computerized Axial Tomography (CT) Scan Head
191 70498 Arterio- Or Venogram (Not Heart And Head)
I2D 70540 Advanced Imaging - MRI, Other
I2D 70542 Advanced Imaging - MRI, Other
I2D 70543 Advanced Imaging - MRI, Other
I2D 70544 Advanced Imaging - MRI, Other
I2D 70545 Advanced Imaging - MRI, Other
I2D 70546 Advanced Imaging - MRI, Other
I2D 70547 Advanced Imaging - MRI, Other
I2D 70548 Advanced Imaging - MRI, Other
I2D 70549 Advanced Imaging - MRI, Other
I2D 70551 Advanced Imaging - MRI, Other
I2D 70552 Advanced Imaging - MRI, Other
I2D 70553 Advanced Imaging - MRI, Other
I2D 70554 Advanced Imaging - MRI, Other
I2D 70555 Advanced Imaging - MRI, Other
I2D 70557 Advanced Imaging - MRI, Other
I2D 70558 Advanced Imaging - MRI, Other
I2D 70559 Advanced Imaging - MRI, Other
183 71045 Routine Chest X-Ray
183 71046 Routine Chest X-Ray
183 71047 Routine Chest X-Ray
183 71048 Routine Chest X-Ray
I1B 71100 Other Diagnostic Radiology And Related Techniques
I1B 71101 Other Diagnostic Radiology And Related Techniques
I1B 71110 Other Diagnostic Radiology And Related Techniques
I1B 71111 Other Diagnostic Radiology And Related Techniques
I1B 71120 Other Diagnostic Radiology And Related Techniques
I1B 71130 Other Diagnostic Radiology And Related Techniques
178 71250 Ct Scan Chest
178 71260 Ct Scan Chest
178 71270 Ct Scan Chest
178 71275 Ct Scan Chest
I2D 71550 Advanced Imaging - MRI, Other
I2D 71551 Advanced Imaging - MRI, Other
I2D 71552 Advanced Imaging - MRI, Other
I2D 71555 Advanced Imaging - MRI, Other
I1B 72020 Other Diagnostic Radiology And Related Techniques
I1B 72040 Other Diagnostic Radiology And Related Techniques
I1B 72050 Other Diagnostic Radiology And Related Techniques
I1B 72052 Other Diagnostic Radiology And Related Techniques
I1B 72070 Other Diagnostic Radiology And Related Techniques
I1B 72072 Other Diagnostic Radiology And Related Techniques
I1B 72074 Other Diagnostic Radiology And Related Techniques
I1B 72080 Other Diagnostic Radiology And Related Techniques
I1B 72081 Other Diagnostic Radiology And Related Techniques
I1B 72082 Other Diagnostic Radiology And Related Techniques
I1B 72083 Other Diagnostic Radiology And Related Techniques
I1B 72084 Other Diagnostic Radiology And Related Techniques
I1B 72100 Other Diagnostic Radiology And Related Techniques
I1B 72110 Other Diagnostic Radiology And Related Techniques
I1B 72114 Other Diagnostic Radiology And Related Techniques
I1B 72120 Other Diagnostic Radiology And Related Techniques
180 72125 Other CT Scan
180 72126 Other CT Scan
180 72127 Other CT Scan
180 72128 Other CT Scan
180 72129 Other CT Scan
180 72130 Other CT Scan
180 72131 Other CT Scan
180 72132 Other CT Scan
180 72133 Other CT Scan
I2D 72141 Advanced Imaging - MRI, Other
Blue Cross NC Proprietary and Confidential 80 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
I2D 72142 Advanced Imaging - MRI, Other
I2D 72146 Advanced Imaging - MRI, Other
I2D 72147 Advanced Imaging - MRI, Other
I2D 72148 Advanced Imaging - MRI, Other
I2D 72149 Advanced Imaging - MRI, Other
I2D 72156 Advanced Imaging - MRI, Other
I2D 72157 Advanced Imaging - MRI, Other
I2D 72158 Advanced Imaging - MRI, Other
I2D 72159 Advanced Imaging - MRI, Other
I1B 72170 Other Diagnostic Radiology And Related Techniques
I1B 72190 Other Diagnostic Radiology And Related Techniques
179 72191 Ct Scan Abdomen
179 72192 Ct Scan Abdomen
179 72193 Ct Scan Abdomen
179 72194 Ct Scan Abdomen
I2D 72195 Advanced Imaging - MRI, Other
I2D 72196 Advanced Imaging - MRI, Other
I2D 72197 Advanced Imaging - MRI, Other
I2D 72198 Advanced Imaging - MRI, Other
I1B 72200 Other Diagnostic Radiology And Related Techniques
I1B 72202 Other Diagnostic Radiology And Related Techniques
I1B 72220 Other Diagnostic Radiology And Related Techniques
181 72240 Myelogram
181 72255 Myelogram
181 72265 Myelogram
181 72270 Myelogram
226 72275 Other Diagnostic Radiology And Related Techniques
209 72285 Radioisotope Scan And Function Studies
209 72295 Radioisotope Scan And Function Studies
I1B 73000 Other Diagnostic Radiology And Related Techniques
I1B 73010 Other Diagnostic Radiology And Related Techniques
I1B 73020 Other Diagnostic Radiology And Related Techniques
I1B 73030 Other Diagnostic Radiology And Related Techniques
226 73040 Other Diagnostic Radiology And Related Techniques
I1B 73050 Other Diagnostic Radiology And Related Techniques
I1B 73060 Other Diagnostic Radiology And Related Techniques
I1B 73070 Other Diagnostic Radiology And Related Techniques
I1B 73080 Other Diagnostic Radiology And Related Techniques
226 73085 Other Diagnostic Radiology And Related Techniques
I1B 73090 Other Diagnostic Radiology And Related Techniques
I1B 73092 Other Diagnostic Radiology And Related Techniques
I1B 73100 Other Diagnostic Radiology And Related Techniques
I1B 73110 Other Diagnostic Radiology And Related Techniques
226 73115 Other Diagnostic Radiology And Related Techniques
I1B 73120 Other Diagnostic Radiology And Related Techniques
I1B 73130 Other Diagnostic Radiology And Related Techniques
I1B 73140 Other Diagnostic Radiology And Related Techniques
180 73200 Other CT Scan
180 73201 Other CT Scan
180 73202 Other CT Scan
180 73206 Other CT Scan
I2D 73218 Advanced Imaging - MRI, Other
I2D 73219 Advanced Imaging - MRI, Other
I2D 73220 Advanced Imaging - MRI, Other
I2D 73221 Advanced Imaging - MRI, Other
I2D 73222 Advanced Imaging - MRI, Other
I2D 73223 Advanced Imaging - MRI, Other
I2D 73225 Advanced Imaging - MRI, Other
I1B 73501 Other Diagnostic Radiology And Related Techniques
I1B 73502 Other Diagnostic Radiology And Related Techniques
I1B 73503 Other Diagnostic Radiology And Related Techniques
I1B 73521 Other Diagnostic Radiology And Related Techniques
I1B 73522 Other Diagnostic Radiology And Related Techniques
I1B 73523 Other Diagnostic Radiology And Related Techniques
226 73525 Other Diagnostic Radiology And Related Techniques
I1B 73551 Other Diagnostic Radiology And Related Techniques
I1B 73552 Other Diagnostic Radiology And Related Techniques
I1B 73560 Other Diagnostic Radiology And Related Techniques
I1B 73562 Other Diagnostic Radiology And Related Techniques
I1B 73564 Other Diagnostic Radiology And Related Techniques
I1B 73565 Other Diagnostic Radiology And Related Techniques
226 73580 Other Diagnostic Radiology And Related Techniques
I1B 73590 Other Diagnostic Radiology And Related Techniques
I1B 73592 Other Diagnostic Radiology And Related Techniques
Blue Cross NC Proprietary and Confidential 81 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
I1B 73600 Other Diagnostic Radiology And Related Techniques
I1B 73610 Other Diagnostic Radiology And Related Techniques
226 73615 Other Diagnostic Radiology And Related Techniques
I1B 73620 Other Diagnostic Radiology And Related Techniques
I1B 73630 Other Diagnostic Radiology And Related Techniques
I1B 73650 Other Diagnostic Radiology And Related Techniques
I1B 73660 Other Diagnostic Radiology And Related Techniques
180 73700 Other CT Scan
180 73701 Other CT Scan
180 73702 Other CT Scan
180 73706 Other CT Scan
I2D 73718 Advanced Imaging - MRI, Other
I2D 73719 Advanced Imaging - MRI, Other
I2D 73720 Advanced Imaging - MRI, Other
I2D 73721 Advanced Imaging - MRI, Other
I2D 73722 Advanced Imaging - MRI, Other
I2D 73723 Advanced Imaging - MRI, Other
I2D 73725 Advanced Imaging - MRI, Other
226 74018 Other Diagnostic Radiology And Related Techniques
226 74019 Other Diagnostic Radiology And Related Techniques
226 74021 Other Diagnostic Radiology And Related Techniques
226 74022 Other Diagnostic Radiology And Related Techniques
179 74150 Ct Scan Abdomen
179 74160 Ct Scan Abdomen
179 74170 Ct Scan Abdomen
179 74174 Ct Scan Abdomen
179 74175 Ct Scan Abdomen
179 74176 Ct Scan Abdomen
179 74177 Ct Scan Abdomen
179 74178 Ct Scan Abdomen
I2D 74181 Advanced Imaging - MRI, Other
I2D 74182 Advanced Imaging - MRI, Other
I2D 74183 Advanced Imaging - MRI, Other
I2D 74185 Advanced Imaging - MRI, Other
226 74190 Other Diagnostic Radiology And Related Techniques
226 74210 Other Diagnostic Radiology And Related Techniques
185 74220 Upper Gastrointestinal X-Ray
185 74221 Upper Gastrointestinal X-Ray
185 74230 Upper Gastrointestinal X-Ray
211 74235 Therapeutic Radiology
185 74240 Upper Gastrointestinal X-Ray
185 74246 Upper Gastrointestinal X-Ray
186 74248 Lower Gastrointestinal X-Ray
185 74250 Upper Gastrointestinal X-Ray
186 74251 Lower Gastrointestinal X-Ray
179 74261 Ct Scan Abdomen
179 74262 Ct Scan Abdomen
179 74263 Ct Scan Abdomen
186 74270 Lower Gastrointestinal X-Ray
186 74280 Lower Gastrointestinal X-Ray
186 74283 Lower Gastrointestinal X-Ray
226 74290 Other Diagnostic Radiology And Related Techniques
184 74300 Intraoperative Cholangiogram
184 74301 Intraoperative Cholangiogram
82 74328 Endoscopic Retrograde Cannulation Of Pancreas (ERCP)
82 74329 Endoscopic Retrograde Cannulation Of Pancreas (ERCP)
82 74330 Endoscopic Retrograde Cannulation Of Pancreas (ERCP)
185 74340 Upper Gastrointestinal X-Ray
226 74355 Other Diagnostic Radiology And Related Techniques
226 74360 Other Diagnostic Radiology And Related Techniques
226 74363 Other Diagnostic Radiology And Related Techniques
187 74400 Intravenous Pyelogram
187 74410 Intravenous Pyelogram
226 74415 Other Diagnostic Radiology And Related Techniques
226 74420 Other Diagnostic Radiology And Related Techniques
226 74425 Other Diagnostic Radiology And Related Techniques
226 74430 Other Diagnostic Radiology And Related Techniques
226 74440 Other Diagnostic Radiology And Related Techniques
226 74445 Other Diagnostic Radiology And Related Techniques
226 74450 Other Diagnostic Radiology And Related Techniques
226 74455 Other Diagnostic Radiology And Related Techniques
226 74470 Other Diagnostic Radiology And Related Techniques
226 74485 Other Diagnostic Radiology And Related Techniques
226 74710 Other Diagnostic Radiology And Related Techniques
Blue Cross NC Proprietary and Confidential 82 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
198 74712 Magnetic Resonance Imaging
198 74713 Magnetic Resonance Imaging
226 74740 Other Diagnostic Radiology And Related Techniques
226 74742 Other Diagnostic Radiology And Related Techniques
226 74775 Other Diagnostic Radiology And Related Techniques
I2D 75557 Advanced Imaging - MRI, Other
I2D 75559 Advanced Imaging - MRI, Other
I2D 75561 Advanced Imaging - MRI, Other
I2D 75563 Advanced Imaging - MRI, Other
I2D 75565 Advanced Imaging - MRI, Other
178 75571 Ct Scan Chest
178 75572 Ct Scan Chest
178 75573 Ct Scan Chest
47 75574 Diagnostic Cardiac Catheterization, Coronary Arteriography
189 75600 Contrast Aortogram
189 75605 Contrast Aortogram
189 75625 Contrast Aortogram
189 75630 Contrast Aortogram
189 75635 Contrast Aortogram
191 75705 Arterio- Or Venogram (Not Heart And Head)
191 75710 Arterio- Or Venogram (Not Heart And Head)
191 75716 Arterio- Or Venogram (Not Heart And Head)
191 75726 Arterio- Or Venogram (Not Heart And Head)
191 75731 Arterio- Or Venogram (Not Heart And Head)
191 75733 Arterio- Or Venogram (Not Heart And Head)
191 75736 Arterio- Or Venogram (Not Heart And Head)
191 75741 Arterio- Or Venogram (Not Heart And Head)
191 75743 Arterio- Or Venogram (Not Heart And Head)
191 75746 Arterio- Or Venogram (Not Heart And Head)
47 75756 Diagnostic Cardiac Catheterization, Coronary Arteriography
191 75774 Arterio- Or Venogram (Not Heart And Head)
226 75801 Other Diagnostic Radiology And Related Techniques
226 75803 Other Diagnostic Radiology And Related Techniques
226 75805 Other Diagnostic Radiology And Related Techniques
226 75807 Other Diagnostic Radiology And Related Techniques
226 75809 Other Diagnostic Radiology And Related Techniques
191 75810 Arterio- Or Venogram (Not Heart And Head)
190 75820 Contrast Arteriogram Of Femoral And Lower Extremity Arteries
190 75822 Contrast Arteriogram Of Femoral And Lower Extremity Arteries
191 75825 Arterio- Or Venogram (Not Heart And Head)
191 75827 Arterio- Or Venogram (Not Heart And Head)
191 75831 Arterio- Or Venogram (Not Heart And Head)
191 75833 Arterio- Or Venogram (Not Heart And Head)
191 75840 Arterio- Or Venogram (Not Heart And Head)
191 75842 Arterio- Or Venogram (Not Heart And Head)
191 75860 Arterio- Or Venogram (Not Heart And Head)
191 75870 Arterio- Or Venogram (Not Heart And Head)
191 75872 Arterio- Or Venogram (Not Heart And Head)
191 75880 Arterio- Or Venogram (Not Heart And Head)
191 75885 Arterio- Or Venogram (Not Heart And Head)
191 75887 Arterio- Or Venogram (Not Heart And Head)
191 75889 Arterio- Or Venogram (Not Heart And Head)
191 75891 Arterio- Or Venogram (Not Heart And Head)
226 75893 Other Diagnostic Radiology And Related Techniques
191 75894 Arterio- Or Venogram (Not Heart And Head)
191 75898 Arterio- Or Venogram (Not Heart And Head)
226 75901 Other Diagnostic Radiology And Related Techniques
226 75902 Other Diagnostic Radiology And Related Techniques
191 75956 Arterio- Or Venogram (Not Heart And Head)
191 75957 Arterio- Or Venogram (Not Heart And Head)
191 75958 Arterio- Or Venogram (Not Heart And Head)
191 75959 Arterio- Or Venogram (Not Heart And Head)
226 75970 Other Diagnostic Radiology And Related Techniques
226 75984 Other Diagnostic Radiology And Related Techniques
226 75989 Other Diagnostic Radiology And Related Techniques
226 76000 Other Diagnostic Radiology And Related Techniques
226 76010 Other Diagnostic Radiology And Related Techniques
226 76080 Other Diagnostic Radiology And Related Techniques
226 76098 Other Diagnostic Radiology And Related Techniques
226 76100 Other Diagnostic Radiology And Related Techniques
226 76101 Other Diagnostic Radiology And Related Techniques
226 76102 Other Diagnostic Radiology And Related Techniques
226 76120 Other Diagnostic Radiology And Related Techniques
226 76125 Other Diagnostic Radiology And Related Techniques
Blue Cross NC Proprietary and Confidential 83 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
226 76140 Other Diagnostic Radiology And Related Techniques
226 76376 Other Diagnostic Radiology And Related Techniques
226 76377 Other Diagnostic Radiology And Related Techniques
180 76380 Other CT Scan
I2D 76390 Advanced Imaging - MRI, Other
198 76391 Magnetic Resonance Imaging
226 76496 Other Diagnostic Radiology And Related Techniques
180 76497 Other CT Scan
I2D 76498 Advanced Imaging - MRI, Other
226 76499 Other Diagnostic Radiology And Related Techniques
192 76506 Diagnostic Ultrasound Of Head And Neck
192 76510 Diagnostic Ultrasound Of Head And Neck
192 76511 Diagnostic Ultrasound Of Head And Neck
192 76512 Diagnostic Ultrasound Of Head And Neck
192 76513 Diagnostic Ultrasound Of Head And Neck
192 76514 Diagnostic Ultrasound Of Head And Neck
192 76516 Diagnostic Ultrasound Of Head And Neck
192 76519 Diagnostic Ultrasound Of Head And Neck
192 76529 Diagnostic Ultrasound Of Head And Neck
192 76536 Diagnostic Ultrasound Of Head And Neck
197 76604 Other Diagnostic Ultrasound
197 76641 Other Diagnostic Ultrasound
197 76642 Other Diagnostic Ultrasound
196 76700 Diagnostic Ultrasound Of Abdomen Or Retroperitoneum
196 76705 Diagnostic Ultrasound Of Abdomen Or Retroperitoneum
196 76706 Diagnostic Ultrasound Of Abdomen Or Retroperitoneum
196 76770 Diagnostic Ultrasound Of Abdomen Or Retroperitoneum
196 76775 Diagnostic Ultrasound Of Abdomen Or Retroperitoneum
195 76776 Diagnostic Ultrasound Of Urinary Tract
197 76800 Other Diagnostic Ultrasound
197 76801 Other Diagnostic Ultrasound
197 76802 Other Diagnostic Ultrasound
197 76805 Other Diagnostic Ultrasound
197 76810 Other Diagnostic Ultrasound
197 76811 Other Diagnostic Ultrasound
197 76812 Other Diagnostic Ultrasound
197 76813 Other Diagnostic Ultrasound
197 76814 Other Diagnostic Ultrasound
197 76815 Other Diagnostic Ultrasound
197 76816 Other Diagnostic Ultrasound
197 76817 Other Diagnostic Ultrasound
197 76818 Other Diagnostic Ultrasound
197 76819 Other Diagnostic Ultrasound
197 76820 Other Diagnostic Ultrasound
197 76821 Other Diagnostic Ultrasound
193 76825 Diagnostic Ultrasound Of Heart (Echocardiogram)
193 76826 Diagnostic Ultrasound Of Heart (Echocardiogram)
193 76827 Diagnostic Ultrasound Of Heart (Echocardiogram)
193 76828 Diagnostic Ultrasound Of Heart (Echocardiogram)
197 76830 Other Diagnostic Ultrasound
197 76831 Other Diagnostic Ultrasound
197 76856 Other Diagnostic Ultrasound
197 76857 Other Diagnostic Ultrasound
197 76870 Other Diagnostic Ultrasound
197 76872 Other Diagnostic Ultrasound
197 76873 Other Diagnostic Ultrasound
197 76881 Other Diagnostic Ultrasound
197 76882 Other Diagnostic Ultrasound
197 76885 Other Diagnostic Ultrasound
197 76886 Other Diagnostic Ultrasound
193 76932 Diagnostic Ultrasound Of Heart (Echocardiogram)
197 76936 Other Diagnostic Ultrasound
197 76937 Other Diagnostic Ultrasound
197 76940 Other Diagnostic Ultrasound
197 76941 Other Diagnostic Ultrasound
197 76942 Other Diagnostic Ultrasound
197 76945 Other Diagnostic Ultrasound
197 76946 Other Diagnostic Ultrasound
197 76948 Other Diagnostic Ultrasound
211 76965 Therapeutic Radiology
197 76970 Other Diagnostic Ultrasound
194 76975 Diagnostic Ultrasound Of Gastrointestinal Tract
197 76977 Other Diagnostic Ultrasound
197 76978 Other Diagnostic Ultrasound
Blue Cross NC Proprietary and Confidential 84 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
197 76979 Other Diagnostic Ultrasound
197 76981 Other Diagnostic Ultrasound
197 76982 Other Diagnostic Ultrasound
197 76983 Other Diagnostic Ultrasound
197 76998 Other Diagnostic Ultrasound
197 76999 Other Diagnostic Ultrasound
226 77001 Other Diagnostic Radiology And Related Techniques
226 77002 Other Diagnostic Radiology And Related Techniques
226 77003 Other Diagnostic Radiology And Related Techniques
180 77011 Other CT Scan
180 77012 Other CT Scan
180 77013 Other CT Scan
180 77014 Other CT Scan
I2D 77021 Advanced Imaging - MRI, Other
I2D 77022 Advanced Imaging - MRI, Other
198 77046 Magnetic Resonance Imaging
198 77047 Magnetic Resonance Imaging
198 77048 Magnetic Resonance Imaging
198 77049 Magnetic Resonance Imaging
182 77053 Mammography
182 77054 Mammography
182 77061 Mammography
182 77062 Mammography
182 77063 Mammography
182 77065 Mammography
182 77066 Mammography
182 77067 Mammography
I1B 77071 Other Diagnostic Radiology And Related Techniques
I1B 77072 Other Diagnostic Radiology And Related Techniques
I1B 77073 Other Diagnostic Radiology And Related Techniques
I1B 77074 Other Diagnostic Radiology And Related Techniques
I1B 77075 Other Diagnostic Radiology And Related Techniques
I1B 77076 Other Diagnostic Radiology And Related Techniques
I1B 77077 Other Diagnostic Radiology And Related Techniques
180 77078 Other CT Scan
I1B 77080 Other Diagnostic Radiology And Related Techniques
I1B 77081 Other Diagnostic Radiology And Related Techniques
I2D 77084 Advanced Imaging - MRI, Other
226 77085 Other Diagnostic Radiology And Related Techniques
226 77086 Other Diagnostic Radiology And Related Techniques
P7A 77261 Oncology - Radiation Therapy
P7A 77262 Oncology - Radiation Therapy
P7A 77263 Oncology - Radiation Therapy
P7A 77280 Oncology - Radiation Therapy
P7A 77285 Oncology - Radiation Therapy
P7A 77290 Oncology - Radiation Therapy
211 77293 Therapeutic Radiology
P7A 77295 Oncology - Radiation Therapy
P7A 77299 Oncology - Radiation Therapy
P7A 77300 Oncology - Radiation Therapy
P7A 77301 Oncology - Radiation Therapy
P7A 77306 Oncology - Radiation Therapy
P7A 77307 Oncology - Radiation Therapy
P7A 77316 Oncology - Radiation Therapy
P7A 77317 Oncology - Radiation Therapy
P7A 77318 Oncology - Radiation Therapy
P7A 77321 Oncology - Radiation Therapy
P7A 77331 Oncology - Radiation Therapy
P7A 77332 Oncology - Radiation Therapy
P7A 77333 Oncology - Radiation Therapy
P7A 77334 Oncology - Radiation Therapy
P7A 77336 Oncology - Radiation Therapy
P7A 77338 Oncology - Radiation Therapy
P7A 77370 Oncology - Radiation Therapy
211 77371 Therapeutic Radiology
211 77372 Therapeutic Radiology
211 77373 Therapeutic Radiology
P7A 77385 Oncology - Radiation Therapy
P7A 77386 Oncology - Radiation Therapy
P7A 77387 Oncology - Radiation Therapy
P7A 77399 Oncology - Radiation Therapy
P7A 77401 Oncology - Radiation Therapy
P7A 77402 Oncology - Radiation Therapy
P7A 77407 Oncology - Radiation Therapy
Blue Cross NC Proprietary and Confidential 85 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
P7A 77412 Oncology - Radiation Therapy
P7A 77417 Oncology - Radiation Therapy
211 77423 Therapeutic Radiology
211 77424 Therapeutic Radiology
211 77425 Therapeutic Radiology
P7A 77427 Oncology - Radiation Therapy
P7A 77431 Oncology - Radiation Therapy
P7A 77432 Oncology - Radiation Therapy
211 77435 Therapeutic Radiology
211 77469 Therapeutic Radiology
P7A 77470 Oncology - Radiation Therapy
P7A 77499 Oncology - Radiation Therapy
P7A 77520 Oncology - Radiation Therapy
P7A 77522 Oncology - Radiation Therapy
P7A 77523 Oncology - Radiation Therapy
P7A 77525 Oncology - Radiation Therapy
211 77600 Therapeutic Radiology
211 77605 Therapeutic Radiology
211 77610 Therapeutic Radiology
211 77615 Therapeutic Radiology
211 77620 Therapeutic Radiology
P7A 77750 Oncology - Radiation Therapy
P7A 77761 Oncology - Radiation Therapy
P7A 77762 Oncology - Radiation Therapy
P7A 77763 Oncology - Radiation Therapy
211 77767 Therapeutic Radiology
211 77768 Therapeutic Radiology
211 77770 Therapeutic Radiology
211 77771 Therapeutic Radiology
211 77772 Therapeutic Radiology
P7A 77778 Oncology - Radiation Therapy
P7A 77789 Oncology - Radiation Therapy
P7A 77790 Oncology - Radiation Therapy
P7A 77799 Oncology - Radiation Therapy
209 78012 Radioisotope Scan And Function Studies
209 78013 Radioisotope Scan And Function Studies
209 78014 Radioisotope Scan And Function Studies
209 78015 Radioisotope Scan And Function Studies
209 78016 Radioisotope Scan And Function Studies
209 78018 Radioisotope Scan And Function Studies
209 78020 Radioisotope Scan And Function Studies
209 78070 Radioisotope Scan And Function Studies
209 78071 Radioisotope Scan And Function Studies
209 78072 Radioisotope Scan And Function Studies
209 78075 Radioisotope Scan And Function Studies
209 78099 Radioisotope Scan And Function Studies
207 78102 Radioisotope Bone Scan
207 78103 Radioisotope Bone Scan
207 78104 Radioisotope Bone Scan
210 78110 Other Radioisotope Scan
210 78111 Other Radioisotope Scan
210 78120 Other Radioisotope Scan
210 78121 Other Radioisotope Scan
210 78122 Other Radioisotope Scan
210 78130 Other Radioisotope Scan
210 78135 Other Radioisotope Scan
210 78140 Other Radioisotope Scan
210 78185 Other Radioisotope Scan
210 78191 Other Radioisotope Scan
209 78195 Radioisotope Scan And Function Studies
210 78199 Other Radioisotope Scan
210 78201 Other Radioisotope Scan
209 78202 Radioisotope Scan And Function Studies
210 78215 Other Radioisotope Scan
209 78216 Radioisotope Scan And Function Studies
209 78226 Radioisotope Scan And Function Studies
209 78227 Radioisotope Scan And Function Studies
210 78230 Other Radioisotope Scan
210 78231 Other Radioisotope Scan
209 78232 Radioisotope Scan And Function Studies
209 78258 Radioisotope Scan And Function Studies
210 78261 Other Radioisotope Scan
209 78262 Radioisotope Scan And Function Studies
209 78264 Radioisotope Scan And Function Studies
Blue Cross NC Proprietary and Confidential 86 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
209 78265 Radioisotope Scan And Function Studies
209 78266 Radioisotope Scan And Function Studies
209 78267 Radioisotope Scan And Function Studies
209 78268 Radioisotope Scan And Function Studies
210 78278 Other Radioisotope Scan
209 78282 Radioisotope Scan And Function Studies
210 78290 Other Radioisotope Scan
209 78291 Radioisotope Scan And Function Studies
210 78299 Other Radioisotope Scan
207 78300 Radioisotope Bone Scan
207 78305 Radioisotope Bone Scan
207 78306 Radioisotope Bone Scan
207 78315 Radioisotope Bone Scan
207 78350 Radioisotope Bone Scan
207 78351 Radioisotope Bone Scan
207 78399 Radioisotope Bone Scan
209 78414 Radioisotope Scan And Function Studies
209 78428 Radioisotope Scan And Function Studies
I2D 78429 Advanced Imaging - MRI, Other
I2D 78430 Advanced Imaging - MRI, Other
I2D 78431 Advanced Imaging - MRI, Other
I2D 78432 Advanced Imaging - MRI, Other
I2D 78433 Advanced Imaging - MRI, Other
I2D 78434 Advanced Imaging - MRI, Other
210 78445 Other Radioisotope Scan
209 78451 Radioisotope Scan And Function Studies
209 78452 Radioisotope Scan And Function Studies
209 78453 Radioisotope Scan And Function Studies
209 78454 Radioisotope Scan And Function Studies
210 78456 Other Radioisotope Scan
210 78457 Other Radioisotope Scan
210 78458 Other Radioisotope Scan
210 78459 Other Radioisotope Scan
210 78466 Other Radioisotope Scan
209 78468 Radioisotope Scan And Function Studies
209 78469 Radioisotope Scan And Function Studies
209 78472 Radioisotope Scan And Function Studies
209 78473 Radioisotope Scan And Function Studies
209 78481 Radioisotope Scan And Function Studies
209 78483 Radioisotope Scan And Function Studies
210 78491 Other Radioisotope Scan
209 78492 Radioisotope Scan And Function Studies
209 78494 Radioisotope Scan And Function Studies
209 78496 Radioisotope Scan And Function Studies
210 78499 Other Radioisotope Scan
208 78579 Radioisotope Pulmonary Scan
208 78580 Radioisotope Pulmonary Scan
208 78582 Radioisotope Pulmonary Scan
208 78597 Radioisotope Pulmonary Scan
208 78598 Radioisotope Pulmonary Scan
208 78599 Radioisotope Pulmonary Scan
210 78600 Other Radioisotope Scan
209 78601 Radioisotope Scan And Function Studies
210 78605 Other Radioisotope Scan
209 78606 Radioisotope Scan And Function Studies
209 78608 Radioisotope Scan And Function Studies
209 78609 Radioisotope Scan And Function Studies
209 78610 Radioisotope Scan And Function Studies
209 78630 Radioisotope Scan And Function Studies
209 78635 Radioisotope Scan And Function Studies
209 78645 Radioisotope Scan And Function Studies
209 78650 Radioisotope Scan And Function Studies
209 78660 Radioisotope Scan And Function Studies
209 78699 Radioisotope Scan And Function Studies
209 78700 Radioisotope Scan And Function Studies
209 78701 Radioisotope Scan And Function Studies
209 78707 Radioisotope Scan And Function Studies
209 78708 Radioisotope Scan And Function Studies
209 78709 Radioisotope Scan And Function Studies
209 78725 Radioisotope Scan And Function Studies
209 78730 Radioisotope Scan And Function Studies
209 78740 Radioisotope Scan And Function Studies
209 78761 Radioisotope Scan And Function Studies
209 78799 Radioisotope Scan And Function Studies
Blue Cross NC Proprietary and Confidential 87 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
209 78800 Radioisotope Scan And Function Studies
209 78801 Radioisotope Scan And Function Studies
209 78802 Radioisotope Scan And Function Studies
209 78803 Radioisotope Scan And Function Studies
209 78804 Radioisotope Scan And Function Studies
209 78808 Radioisotope Scan And Function Studies
209 78811 Radioisotope Scan And Function Studies
I2D 78812 Advanced Imaging - MRI, Other
I2D 78813 Advanced Imaging - MRI, Other
I2D 78814 Advanced Imaging - MRI, Other
I2D 78815 Advanced Imaging - MRI, Other
I2D 78816 Advanced Imaging - MRI, Other
I2D 78830 Advanced Imaging - MRI, Other
I2D 78831 Advanced Imaging - MRI, Other
I2D 78832 Advanced Imaging - MRI, Other
I2D 78835 Advanced Imaging - MRI, Other
209 78999 Radioisotope Scan And Function Studies
12 79005 Other Therapeutic Endocrine Procedures
211 79101 Therapeutic Radiology
P7A 79200 Oncology - Radiation Therapy
P7A 79300 Oncology - Radiation Therapy
211 79403 Therapeutic Radiology
163 79440 Other Non-Or Therapeutic Procedures On Musculoskeletal System
163 79445 Other Non-Or Therapeutic Procedures On Musculoskeletal System
237 79999 Ancillary Services
233 80047 Laboratory - Chemistry And Hematology
233 80048 Laboratory - Chemistry And Hematology
233 80050 Laboratory - Chemistry And Hematology
233 80051 Laboratory - Chemistry And Hematology
233 80053 Laboratory - Chemistry And Hematology
235 80055 Other Laboratory
235 80061 Other Laboratory
233 80069 Laboratory - Chemistry And Hematology
235 80074 Other Laboratory
235 80076 Other Laboratory
235 80081 Other Laboratory
233 80145 Laboratory - Chemistry And Hematology
235 80150 Other Laboratory
235 80155 Other Laboratory
235 80156 Other Laboratory
235 80157 Other Laboratory
235 80158 Other Laboratory
235 80159 Other Laboratory
235 80162 Other Laboratory
235 80163 Other Laboratory
235 80164 Other Laboratory
235 80165 Other Laboratory
235 80168 Other Laboratory
235 80169 Other Laboratory
235 80170 Other Laboratory
235 80171 Other Laboratory
235 80173 Other Laboratory
235 80175 Other Laboratory
235 80176 Other Laboratory
235 80177 Other Laboratory
235 80178 Other Laboratory
235 80180 Other Laboratory
235 80183 Other Laboratory
235 80184 Other Laboratory
235 80185 Other Laboratory
235 80186 Other Laboratory
233 80187 Laboratory - Chemistry And Hematology
235 80188 Other Laboratory
235 80190 Other Laboratory
235 80192 Other Laboratory
235 80194 Other Laboratory
235 80195 Other Laboratory
235 80197 Other Laboratory
235 80198 Other Laboratory
235 80199 Other Laboratory
235 80200 Other Laboratory
235 80201 Other Laboratory
235 80202 Other Laboratory
235 80203 Other Laboratory
Blue Cross NC Proprietary and Confidential 88 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
233 80230 Laboratory - Chemistry And Hematology
233 80235 Laboratory - Chemistry And Hematology
233 80280 Laboratory - Chemistry And Hematology
233 80285 Laboratory - Chemistry And Hematology
235 80299 Other Laboratory
235 80305 Other Laboratory
235 80306 Other Laboratory
235 80307 Other Laboratory
235 80320 Other Laboratory
235 80321 Other Laboratory
235 80322 Other Laboratory
235 80323 Other Laboratory
235 80324 Other Laboratory
235 80325 Other Laboratory
235 80326 Other Laboratory
235 80327 Other Laboratory
235 80328 Other Laboratory
235 80329 Other Laboratory
235 80330 Other Laboratory
235 80331 Other Laboratory
235 80332 Other Laboratory
235 80333 Other Laboratory
235 80334 Other Laboratory
235 80335 Other Laboratory
235 80336 Other Laboratory
235 80337 Other Laboratory
235 80338 Other Laboratory
235 80339 Other Laboratory
235 80340 Other Laboratory
235 80341 Other Laboratory
235 80342 Other Laboratory
235 80343 Other Laboratory
235 80344 Other Laboratory
235 80345 Other Laboratory
235 80346 Other Laboratory
235 80347 Other Laboratory
235 80348 Other Laboratory
235 80349 Other Laboratory
235 80350 Other Laboratory
235 80351 Other Laboratory
235 80352 Other Laboratory
235 80353 Other Laboratory
235 80354 Other Laboratory
235 80355 Other Laboratory
235 80356 Other Laboratory
235 80357 Other Laboratory
235 80358 Other Laboratory
235 80359 Other Laboratory
235 80360 Other Laboratory
235 80361 Other Laboratory
235 80362 Other Laboratory
235 80363 Other Laboratory
235 80364 Other Laboratory
235 80365 Other Laboratory
235 80366 Other Laboratory
235 80367 Other Laboratory
235 80368 Other Laboratory
235 80369 Other Laboratory
235 80370 Other Laboratory
235 80371 Other Laboratory
235 80372 Other Laboratory
235 80373 Other Laboratory
235 80374 Other Laboratory
235 80375 Other Laboratory
235 80376 Other Laboratory
235 80377 Other Laboratory
235 80400 Other Laboratory
235 80402 Other Laboratory
235 80406 Other Laboratory
235 80408 Other Laboratory
235 80410 Other Laboratory
235 80412 Other Laboratory
235 80414 Other Laboratory
235 80415 Other Laboratory
Blue Cross NC Proprietary and Confidential 89 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
235 80416 Other Laboratory
235 80417 Other Laboratory
235 80418 Other Laboratory
235 80420 Other Laboratory
235 80422 Other Laboratory
235 80424 Other Laboratory
235 80426 Other Laboratory
235 80428 Other Laboratory
235 80430 Other Laboratory
235 80432 Other Laboratory
235 80434 Other Laboratory
235 80435 Other Laboratory
235 80436 Other Laboratory
235 80438 Other Laboratory
235 80439 Other Laboratory
234 80500 Pathology
234 80502 Pathology
206 81000 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 81001 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
200 81002 Nonoperative Urinary System Measurements
200 81003 Nonoperative Urinary System Measurements
200 81005 Nonoperative Urinary System Measurements
206 81007 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 81015 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 81020 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
200 81025 Nonoperative Urinary System Measurements
200 81050 Nonoperative Urinary System Measurements
200 81099 Nonoperative Urinary System Measurements
234 81105 Pathology
234 81106 Pathology
234 81107 Pathology
234 81108 Pathology
234 81109 Pathology
234 81110 Pathology
234 81111 Pathology
234 81112 Pathology
234 81120 Pathology
234 81121 Pathology
234 81161 Pathology
234 81162 Pathology
235 81163 Other Laboratory
235 81164 Other Laboratory
235 81165 Other Laboratory
235 81166 Other Laboratory
235 81167 Other Laboratory
234 81170 Pathology
235 81171 Other Laboratory
235 81172 Other Laboratory
235 81173 Other Laboratory
235 81174 Other Laboratory
234 81175 Pathology
234 81176 Pathology
235 81177 Other Laboratory
235 81178 Other Laboratory
235 81179 Other Laboratory
235 81180 Other Laboratory
235 81181 Other Laboratory
235 81182 Other Laboratory
235 81183 Other Laboratory
235 81184 Other Laboratory
235 81185 Other Laboratory
235 81186 Other Laboratory
235 81187 Other Laboratory
235 81188 Other Laboratory
235 81189 Other Laboratory
235 81190 Other Laboratory
234 81200 Pathology
234 81201 Pathology
234 81202 Pathology
234 81203 Pathology
235 81204 Other Laboratory
234 81205 Pathology
234 81206 Pathology
234 81207 Pathology
Blue Cross NC Proprietary and Confidential 90 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
234 81208 Pathology
234 81209 Pathology
234 81210 Pathology
234 81212 Pathology
234 81215 Pathology
234 81216 Pathology
234 81217 Pathology
234 81218 Pathology
234 81219 Pathology
234 81220 Pathology
234 81221 Pathology
234 81222 Pathology
234 81223 Pathology
234 81224 Pathology
234 81225 Pathology
234 81226 Pathology
234 81227 Pathology
234 81228 Pathology
234 81229 Pathology
234 81230 Pathology
234 81231 Pathology
234 81232 Pathology
235 81233 Other Laboratory
235 81234 Other Laboratory
234 81235 Pathology
235 81236 Other Laboratory
235 81237 Other Laboratory
234 81238 Pathology
235 81239 Other Laboratory
234 81240 Pathology
234 81241 Pathology
234 81242 Pathology
234 81243 Pathology
234 81244 Pathology
234 81245 Pathology
234 81246 Pathology
234 81247 Pathology
234 81248 Pathology
234 81249 Pathology
234 81250 Pathology
234 81251 Pathology
234 81252 Pathology
234 81253 Pathology
234 81254 Pathology
234 81255 Pathology
234 81256 Pathology
234 81257 Pathology
234 81258 Pathology
234 81259 Pathology
234 81260 Pathology
234 81261 Pathology
234 81262 Pathology
234 81263 Pathology
234 81264 Pathology
234 81265 Pathology
234 81266 Pathology
234 81267 Pathology
234 81268 Pathology
234 81269 Pathology
234 81270 Pathology
235 81271 Other Laboratory
234 81272 Pathology
234 81273 Pathology
235 81274 Other Laboratory
234 81275 Pathology
234 81276 Pathology
234 81277 Pathology
234 81283 Pathology
235 81284 Other Laboratory
235 81285 Other Laboratory
235 81286 Other Laboratory
234 81287 Pathology
234 81288 Pathology
235 81289 Other Laboratory
Blue Cross NC Proprietary and Confidential 91 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
234 81290 Pathology
234 81291 Pathology
234 81292 Pathology
234 81293 Pathology
234 81294 Pathology
234 81295 Pathology
234 81296 Pathology
234 81297 Pathology
234 81298 Pathology
234 81299 Pathology
234 81300 Pathology
234 81301 Pathology
234 81302 Pathology
234 81303 Pathology
234 81304 Pathology
235 81305 Other Laboratory
235 81306 Other Laboratory
234 81307 Pathology
234 81308 Pathology
234 81309 Pathology
234 81310 Pathology
234 81311 Pathology
235 81312 Other Laboratory
234 81313 Pathology
234 81314 Pathology
234 81315 Pathology
234 81316 Pathology
234 81317 Pathology
234 81318 Pathology
234 81319 Pathology
235 81320 Other Laboratory
234 81321 Pathology
234 81322 Pathology
234 81323 Pathology
234 81324 Pathology
234 81325 Pathology
234 81326 Pathology
234 81327 Pathology
234 81328 Pathology
235 81329 Other Laboratory
234 81330 Pathology
234 81331 Pathology
234 81332 Pathology
235 81333 Other Laboratory
234 81334 Pathology
234 81335 Pathology
235 81336 Other Laboratory
235 81337 Other Laboratory
234 81340 Pathology
234 81341 Pathology
234 81342 Pathology
235 81343 Other Laboratory
235 81344 Other Laboratory
235 81345 Other Laboratory
234 81346 Pathology
234 81350 Pathology
234 81355 Pathology
234 81361 Pathology
234 81362 Pathology
234 81363 Pathology
234 81364 Pathology
234 81370 Pathology
234 81371 Pathology
234 81372 Pathology
234 81373 Pathology
234 81374 Pathology
234 81375 Pathology
234 81376 Pathology
234 81377 Pathology
234 81378 Pathology
234 81379 Pathology
234 81380 Pathology
234 81381 Pathology
234 81382 Pathology
Blue Cross NC Proprietary and Confidential 92 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
234 81383 Pathology
234 81400 Pathology
234 81401 Pathology
234 81402 Pathology
234 81403 Pathology
234 81404 Pathology
234 81405 Pathology
234 81406 Pathology
234 81407 Pathology
234 81408 Pathology
234 81410 Pathology
234 81411 Pathology
234 81412 Pathology
234 81413 Pathology
234 81414 Pathology
234 81415 Pathology
234 81416 Pathology
234 81417 Pathology
234 81420 Pathology
234 81422 Pathology
234 81425 Pathology
234 81426 Pathology
234 81427 Pathology
234 81430 Pathology
234 81431 Pathology
234 81432 Pathology
234 81433 Pathology
234 81434 Pathology
234 81435 Pathology
234 81436 Pathology
234 81437 Pathology
234 81438 Pathology
234 81439 Pathology
234 81440 Pathology
234 81442 Pathology
235 81443 Other Laboratory
234 81445 Pathology
234 81448 Pathology
234 81450 Pathology
234 81455 Pathology
234 81460 Pathology
234 81465 Pathology
234 81470 Pathology
234 81471 Pathology
234 81479 Pathology
234 81490 Pathology
234 81493 Pathology
234 81500 Pathology
234 81503 Pathology
234 81504 Pathology
234 81506 Pathology
234 81507 Pathology
234 81508 Pathology
234 81509 Pathology
234 81511 Pathology
234 81512 Pathology
235 81518 Other Laboratory
234 81519 Pathology
234 81520 Pathology
234 81521 Pathology
234 81522 Pathology
234 81525 Pathology
234 81528 Pathology
234 81535 Pathology
234 81536 Pathology
234 81538 Pathology
234 81539 Pathology
234 81540 Pathology
234 81541 Pathology
234 81542 Pathology
234 81545 Pathology
234 81551 Pathology
234 81552 Pathology
234 81595 Pathology
Blue Cross NC Proprietary and Confidential 93 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
235 81596 Other Laboratory
234 81599 Pathology
233 82009 Laboratory - Chemistry And Hematology
233 82010 Laboratory - Chemistry And Hematology
233 82013 Laboratory - Chemistry And Hematology
233 82016 Laboratory - Chemistry And Hematology
233 82017 Laboratory - Chemistry And Hematology
233 82024 Laboratory - Chemistry And Hematology
233 82030 Laboratory - Chemistry And Hematology
233 82040 Laboratory - Chemistry And Hematology
200 82042 Nonoperative Urinary System Measurements
206 82043 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 82044 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 82045 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
233 82075 Laboratory - Chemistry And Hematology
233 82085 Laboratory - Chemistry And Hematology
233 82088 Laboratory - Chemistry And Hematology
233 82103 Laboratory - Chemistry And Hematology
233 82104 Laboratory - Chemistry And Hematology
233 82105 Laboratory - Chemistry And Hematology
233 82106 Laboratory - Chemistry And Hematology
233 82107 Laboratory - Chemistry And Hematology
233 82108 Laboratory - Chemistry And Hematology
206 82120 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 82127 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 82128 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
200 82131 Nonoperative Urinary System Measurements
233 82135 Laboratory - Chemistry And Hematology
233 82136 Laboratory - Chemistry And Hematology
233 82139 Laboratory - Chemistry And Hematology
233 82140 Laboratory - Chemistry And Hematology
233 82143 Laboratory - Chemistry And Hematology
233 82150 Laboratory - Chemistry And Hematology
233 82154 Laboratory - Chemistry And Hematology
233 82157 Laboratory - Chemistry And Hematology
233 82160 Laboratory - Chemistry And Hematology
233 82163 Laboratory - Chemistry And Hematology
233 82164 Laboratory - Chemistry And Hematology
233 82172 Laboratory - Chemistry And Hematology
206 82175 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
233 82180 Laboratory - Chemistry And Hematology
233 82190 Laboratory - Chemistry And Hematology
235 82232 Other Laboratory
233 82239 Laboratory - Chemistry And Hematology
233 82240 Laboratory - Chemistry And Hematology
233 82247 Laboratory - Chemistry And Hematology
233 82248 Laboratory - Chemistry And Hematology
233 82252 Laboratory - Chemistry And Hematology
233 82261 Laboratory - Chemistry And Hematology
233 82270 Laboratory - Chemistry And Hematology
235 82271 Other Laboratory
235 82272 Other Laboratory
233 82274 Laboratory - Chemistry And Hematology
233 82286 Laboratory - Chemistry And Hematology
233 82300 Laboratory - Chemistry And Hematology
233 82306 Laboratory - Chemistry And Hematology
233 82308 Laboratory - Chemistry And Hematology
233 82310 Laboratory - Chemistry And Hematology
233 82330 Laboratory - Chemistry And Hematology
233 82331 Laboratory - Chemistry And Hematology
233 82340 Laboratory - Chemistry And Hematology
233 82355 Laboratory - Chemistry And Hematology
233 82360 Laboratory - Chemistry And Hematology
233 82365 Laboratory - Chemistry And Hematology
233 82370 Laboratory - Chemistry And Hematology
233 82373 Laboratory - Chemistry And Hematology
233 82374 Laboratory - Chemistry And Hematology
233 82375 Laboratory - Chemistry And Hematology
233 82376 Laboratory - Chemistry And Hematology
233 82378 Laboratory - Chemistry And Hematology
233 82379 Laboratory - Chemistry And Hematology
233 82380 Laboratory - Chemistry And Hematology
233 82382 Laboratory - Chemistry And Hematology
233 82383 Laboratory - Chemistry And Hematology
Blue Cross NC Proprietary and Confidential 94 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
233 82384 Laboratory - Chemistry And Hematology
233 82387 Laboratory - Chemistry And Hematology
233 82390 Laboratory - Chemistry And Hematology
233 82397 Laboratory - Chemistry And Hematology
233 82415 Laboratory - Chemistry And Hematology
233 82435 Laboratory - Chemistry And Hematology
233 82436 Laboratory - Chemistry And Hematology
233 82438 Laboratory - Chemistry And Hematology
233 82441 Laboratory - Chemistry And Hematology
233 82465 Laboratory - Chemistry And Hematology
233 82480 Laboratory - Chemistry And Hematology
233 82482 Laboratory - Chemistry And Hematology
233 82485 Laboratory - Chemistry And Hematology
233 82495 Laboratory - Chemistry And Hematology
233 82507 Laboratory - Chemistry And Hematology
233 82523 Laboratory - Chemistry And Hematology
233 82525 Laboratory - Chemistry And Hematology
233 82528 Laboratory - Chemistry And Hematology
233 82530 Laboratory - Chemistry And Hematology
233 82533 Laboratory - Chemistry And Hematology
233 82540 Laboratory - Chemistry And Hematology
233 82542 Laboratory - Chemistry And Hematology
233 82550 Laboratory - Chemistry And Hematology
233 82552 Laboratory - Chemistry And Hematology
233 82553 Laboratory - Chemistry And Hematology
233 82554 Laboratory - Chemistry And Hematology
233 82565 Laboratory - Chemistry And Hematology
233 82570 Laboratory - Chemistry And Hematology
233 82575 Laboratory - Chemistry And Hematology
233 82585 Laboratory - Chemistry And Hematology
233 82595 Laboratory - Chemistry And Hematology
233 82600 Laboratory - Chemistry And Hematology
233 82607 Laboratory - Chemistry And Hematology
233 82608 Laboratory - Chemistry And Hematology
233 82610 Laboratory - Chemistry And Hematology
233 82615 Laboratory - Chemistry And Hematology
233 82626 Laboratory - Chemistry And Hematology
233 82627 Laboratory - Chemistry And Hematology
233 82633 Laboratory - Chemistry And Hematology
233 82634 Laboratory - Chemistry And Hematology
233 82638 Laboratory - Chemistry And Hematology
235 82642 Other Laboratory
233 82652 Laboratory - Chemistry And Hematology
233 82656 Laboratory - Chemistry And Hematology
233 82657 Laboratory - Chemistry And Hematology
233 82658 Laboratory - Chemistry And Hematology
233 82664 Laboratory - Chemistry And Hematology
233 82668 Laboratory - Chemistry And Hematology
233 82670 Laboratory - Chemistry And Hematology
233 82671 Laboratory - Chemistry And Hematology
233 82672 Laboratory - Chemistry And Hematology
233 82677 Laboratory - Chemistry And Hematology
233 82679 Laboratory - Chemistry And Hematology
233 82693 Laboratory - Chemistry And Hematology
233 82696 Laboratory - Chemistry And Hematology
233 82705 Laboratory - Chemistry And Hematology
233 82710 Laboratory - Chemistry And Hematology
233 82715 Laboratory - Chemistry And Hematology
233 82725 Laboratory - Chemistry And Hematology
233 82726 Laboratory - Chemistry And Hematology
233 82728 Laboratory - Chemistry And Hematology
233 82731 Laboratory - Chemistry And Hematology
233 82735 Laboratory - Chemistry And Hematology
233 82746 Laboratory - Chemistry And Hematology
233 82747 Laboratory - Chemistry And Hematology
233 82757 Laboratory - Chemistry And Hematology
233 82759 Laboratory - Chemistry And Hematology
233 82760 Laboratory - Chemistry And Hematology
233 82775 Laboratory - Chemistry And Hematology
233 82776 Laboratory - Chemistry And Hematology
233 82777 Laboratory - Chemistry And Hematology
233 82784 Laboratory - Chemistry And Hematology
233 82785 Laboratory - Chemistry And Hematology
233 82787 Laboratory - Chemistry And Hematology
Blue Cross NC Proprietary and Confidential 95 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
205 82800 Arterial Blood Gases
205 82803 Arterial Blood Gases
205 82805 Arterial Blood Gases
205 82810 Arterial Blood Gases
233 82820 Laboratory - Chemistry And Hematology
233 82930 Laboratory - Chemistry And Hematology
233 82938 Laboratory - Chemistry And Hematology
233 82941 Laboratory - Chemistry And Hematology
233 82943 Laboratory - Chemistry And Hematology
233 82945 Laboratory - Chemistry And Hematology
233 82946 Laboratory - Chemistry And Hematology
233 82947 Laboratory - Chemistry And Hematology
233 82948 Laboratory - Chemistry And Hematology
233 82950 Laboratory - Chemistry And Hematology
233 82951 Laboratory - Chemistry And Hematology
233 82952 Laboratory - Chemistry And Hematology
233 82955 Laboratory - Chemistry And Hematology
233 82960 Laboratory - Chemistry And Hematology
233 82962 Laboratory - Chemistry And Hematology
233 82963 Laboratory - Chemistry And Hematology
233 82965 Laboratory - Chemistry And Hematology
233 82977 Laboratory - Chemistry And Hematology
233 82978 Laboratory - Chemistry And Hematology
233 82979 Laboratory - Chemistry And Hematology
233 82985 Laboratory - Chemistry And Hematology
233 83001 Laboratory - Chemistry And Hematology
233 83002 Laboratory - Chemistry And Hematology
233 83003 Laboratory - Chemistry And Hematology
233 83006 Laboratory - Chemistry And Hematology
233 83009 Laboratory - Chemistry And Hematology
233 83010 Laboratory - Chemistry And Hematology
233 83012 Laboratory - Chemistry And Hematology
233 83013 Laboratory - Chemistry And Hematology
233 83014 Laboratory - Chemistry And Hematology
206 83015 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 83018 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
233 83020 Laboratory - Chemistry And Hematology
233 83021 Laboratory - Chemistry And Hematology
233 83026 Laboratory - Chemistry And Hematology
233 83030 Laboratory - Chemistry And Hematology
233 83033 Laboratory - Chemistry And Hematology
233 83036 Laboratory - Chemistry And Hematology
233 83037 Laboratory - Chemistry And Hematology
233 83045 Laboratory - Chemistry And Hematology
233 83050 Laboratory - Chemistry And Hematology
233 83051 Laboratory - Chemistry And Hematology
233 83060 Laboratory - Chemistry And Hematology
233 83065 Laboratory - Chemistry And Hematology
233 83068 Laboratory - Chemistry And Hematology
233 83069 Laboratory - Chemistry And Hematology
233 83070 Laboratory - Chemistry And Hematology
233 83080 Laboratory - Chemistry And Hematology
233 83088 Laboratory - Chemistry And Hematology
233 83090 Laboratory - Chemistry And Hematology
233 83150 Laboratory - Chemistry And Hematology
233 83491 Laboratory - Chemistry And Hematology
233 83497 Laboratory - Chemistry And Hematology
233 83498 Laboratory - Chemistry And Hematology
233 83500 Laboratory - Chemistry And Hematology
233 83505 Laboratory - Chemistry And Hematology
233 83516 Laboratory - Chemistry And Hematology
233 83518 Laboratory - Chemistry And Hematology
233 83519 Laboratory - Chemistry And Hematology
233 83520 Laboratory - Chemistry And Hematology
233 83525 Laboratory - Chemistry And Hematology
233 83527 Laboratory - Chemistry And Hematology
233 83528 Laboratory - Chemistry And Hematology
233 83540 Laboratory - Chemistry And Hematology
233 83550 Laboratory - Chemistry And Hematology
233 83570 Laboratory - Chemistry And Hematology
233 83582 Laboratory - Chemistry And Hematology
233 83586 Laboratory - Chemistry And Hematology
233 83593 Laboratory - Chemistry And Hematology
233 83605 Laboratory - Chemistry And Hematology
Blue Cross NC Proprietary and Confidential 96 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
233 83615 Laboratory - Chemistry And Hematology
233 83625 Laboratory - Chemistry And Hematology
233 83630 Laboratory - Chemistry And Hematology
233 83631 Laboratory - Chemistry And Hematology
233 83632 Laboratory - Chemistry And Hematology
233 83633 Laboratory - Chemistry And Hematology
233 83655 Laboratory - Chemistry And Hematology
233 83661 Laboratory - Chemistry And Hematology
233 83662 Laboratory - Chemistry And Hematology
233 83663 Laboratory - Chemistry And Hematology
233 83664 Laboratory - Chemistry And Hematology
233 83670 Laboratory - Chemistry And Hematology
233 83690 Laboratory - Chemistry And Hematology
233 83695 Laboratory - Chemistry And Hematology
233 83698 Laboratory - Chemistry And Hematology
233 83700 Laboratory - Chemistry And Hematology
233 83701 Laboratory - Chemistry And Hematology
233 83704 Laboratory - Chemistry And Hematology
233 83718 Laboratory - Chemistry And Hematology
233 83719 Laboratory - Chemistry And Hematology
233 83721 Laboratory - Chemistry And Hematology
235 83722 Other Laboratory
233 83727 Laboratory - Chemistry And Hematology
233 83735 Laboratory - Chemistry And Hematology
233 83775 Laboratory - Chemistry And Hematology
233 83785 Laboratory - Chemistry And Hematology
233 83789 Laboratory - Chemistry And Hematology
233 83825 Laboratory - Chemistry And Hematology
233 83835 Laboratory - Chemistry And Hematology
233 83857 Laboratory - Chemistry And Hematology
233 83861 Laboratory - Chemistry And Hematology
233 83864 Laboratory - Chemistry And Hematology
233 83872 Laboratory - Chemistry And Hematology
233 83873 Laboratory - Chemistry And Hematology
233 83874 Laboratory - Chemistry And Hematology
233 83876 Laboratory - Chemistry And Hematology
233 83880 Laboratory - Chemistry And Hematology
233 83883 Laboratory - Chemistry And Hematology
233 83885 Laboratory - Chemistry And Hematology
233 83915 Laboratory - Chemistry And Hematology
233 83916 Laboratory - Chemistry And Hematology
233 83918 Laboratory - Chemistry And Hematology
233 83919 Laboratory - Chemistry And Hematology
233 83921 Laboratory - Chemistry And Hematology
233 83930 Laboratory - Chemistry And Hematology
233 83935 Laboratory - Chemistry And Hematology
233 83937 Laboratory - Chemistry And Hematology
233 83945 Laboratory - Chemistry And Hematology
233 83950 Laboratory - Chemistry And Hematology
233 83951 Laboratory - Chemistry And Hematology
233 83970 Laboratory - Chemistry And Hematology
233 83986 Laboratory - Chemistry And Hematology
233 83987 Laboratory - Chemistry And Hematology
233 83992 Laboratory - Chemistry And Hematology
233 83993 Laboratory - Chemistry And Hematology
233 84030 Laboratory - Chemistry And Hematology
233 84035 Laboratory - Chemistry And Hematology
233 84060 Laboratory - Chemistry And Hematology
233 84066 Laboratory - Chemistry And Hematology
233 84075 Laboratory - Chemistry And Hematology
233 84078 Laboratory - Chemistry And Hematology
233 84080 Laboratory - Chemistry And Hematology
233 84081 Laboratory - Chemistry And Hematology
233 84085 Laboratory - Chemistry And Hematology
233 84087 Laboratory - Chemistry And Hematology
233 84100 Laboratory - Chemistry And Hematology
233 84105 Laboratory - Chemistry And Hematology
233 84106 Laboratory - Chemistry And Hematology
233 84110 Laboratory - Chemistry And Hematology
233 84112 Laboratory - Chemistry And Hematology
233 84119 Laboratory - Chemistry And Hematology
233 84120 Laboratory - Chemistry And Hematology
233 84126 Laboratory - Chemistry And Hematology
233 84132 Laboratory - Chemistry And Hematology
Blue Cross NC Proprietary and Confidential 97 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
233 84133 Laboratory - Chemistry And Hematology
233 84134 Laboratory - Chemistry And Hematology
233 84135 Laboratory - Chemistry And Hematology
233 84138 Laboratory - Chemistry And Hematology
233 84140 Laboratory - Chemistry And Hematology
233 84143 Laboratory - Chemistry And Hematology
233 84144 Laboratory - Chemistry And Hematology
233 84145 Laboratory - Chemistry And Hematology
233 84146 Laboratory - Chemistry And Hematology
233 84150 Laboratory - Chemistry And Hematology
233 84152 Laboratory - Chemistry And Hematology
233 84153 Laboratory - Chemistry And Hematology
233 84154 Laboratory - Chemistry And Hematology
233 84155 Laboratory - Chemistry And Hematology
233 84156 Laboratory - Chemistry And Hematology
233 84157 Laboratory - Chemistry And Hematology
233 84160 Laboratory - Chemistry And Hematology
233 84163 Laboratory - Chemistry And Hematology
233 84165 Laboratory - Chemistry And Hematology
233 84166 Laboratory - Chemistry And Hematology
233 84181 Laboratory - Chemistry And Hematology
233 84182 Laboratory - Chemistry And Hematology
233 84202 Laboratory - Chemistry And Hematology
233 84203 Laboratory - Chemistry And Hematology
233 84206 Laboratory - Chemistry And Hematology
233 84207 Laboratory - Chemistry And Hematology
233 84210 Laboratory - Chemistry And Hematology
233 84220 Laboratory - Chemistry And Hematology
233 84228 Laboratory - Chemistry And Hematology
233 84233 Laboratory - Chemistry And Hematology
233 84234 Laboratory - Chemistry And Hematology
233 84235 Laboratory - Chemistry And Hematology
233 84238 Laboratory - Chemistry And Hematology
233 84244 Laboratory - Chemistry And Hematology
233 84252 Laboratory - Chemistry And Hematology
233 84255 Laboratory - Chemistry And Hematology
233 84260 Laboratory - Chemistry And Hematology
233 84270 Laboratory - Chemistry And Hematology
233 84275 Laboratory - Chemistry And Hematology
233 84285 Laboratory - Chemistry And Hematology
233 84295 Laboratory - Chemistry And Hematology
233 84300 Laboratory - Chemistry And Hematology
233 84302 Laboratory - Chemistry And Hematology
233 84305 Laboratory - Chemistry And Hematology
233 84307 Laboratory - Chemistry And Hematology
233 84311 Laboratory - Chemistry And Hematology
233 84315 Laboratory - Chemistry And Hematology
233 84375 Laboratory - Chemistry And Hematology
233 84376 Laboratory - Chemistry And Hematology
233 84377 Laboratory - Chemistry And Hematology
233 84378 Laboratory - Chemistry And Hematology
233 84379 Laboratory - Chemistry And Hematology
233 84392 Laboratory - Chemistry And Hematology
233 84402 Laboratory - Chemistry And Hematology
233 84403 Laboratory - Chemistry And Hematology
233 84410 Laboratory - Chemistry And Hematology
233 84425 Laboratory - Chemistry And Hematology
233 84430 Laboratory - Chemistry And Hematology
233 84431 Laboratory - Chemistry And Hematology
233 84432 Laboratory - Chemistry And Hematology
233 84436 Laboratory - Chemistry And Hematology
233 84437 Laboratory - Chemistry And Hematology
233 84439 Laboratory - Chemistry And Hematology
233 84442 Laboratory - Chemistry And Hematology
233 84443 Laboratory - Chemistry And Hematology
233 84445 Laboratory - Chemistry And Hematology
233 84446 Laboratory - Chemistry And Hematology
233 84449 Laboratory - Chemistry And Hematology
233 84450 Laboratory - Chemistry And Hematology
233 84460 Laboratory - Chemistry And Hematology
233 84466 Laboratory - Chemistry And Hematology
233 84478 Laboratory - Chemistry And Hematology
233 84479 Laboratory - Chemistry And Hematology
233 84480 Laboratory - Chemistry And Hematology
Blue Cross NC Proprietary and Confidential 98 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
233 84481 Laboratory - Chemistry And Hematology
233 84482 Laboratory - Chemistry And Hematology
233 84484 Laboratory - Chemistry And Hematology
233 84485 Laboratory - Chemistry And Hematology
233 84488 Laboratory - Chemistry And Hematology
233 84490 Laboratory - Chemistry And Hematology
233 84510 Laboratory - Chemistry And Hematology
233 84512 Laboratory - Chemistry And Hematology
233 84520 Laboratory - Chemistry And Hematology
233 84525 Laboratory - Chemistry And Hematology
233 84540 Laboratory - Chemistry And Hematology
233 84545 Laboratory - Chemistry And Hematology
233 84550 Laboratory - Chemistry And Hematology
233 84560 Laboratory - Chemistry And Hematology
233 84577 Laboratory - Chemistry And Hematology
233 84578 Laboratory - Chemistry And Hematology
233 84580 Laboratory - Chemistry And Hematology
233 84583 Laboratory - Chemistry And Hematology
233 84585 Laboratory - Chemistry And Hematology
233 84586 Laboratory - Chemistry And Hematology
233 84588 Laboratory - Chemistry And Hematology
233 84590 Laboratory - Chemistry And Hematology
233 84591 Laboratory - Chemistry And Hematology
233 84597 Laboratory - Chemistry And Hematology
233 84600 Laboratory - Chemistry And Hematology
233 84620 Laboratory - Chemistry And Hematology
233 84630 Laboratory - Chemistry And Hematology
233 84681 Laboratory - Chemistry And Hematology
233 84702 Laboratory - Chemistry And Hematology
233 84703 Laboratory - Chemistry And Hematology
233 84704 Laboratory - Chemistry And Hematology
233 84830 Laboratory - Chemistry And Hematology
233 84999 Laboratory - Chemistry And Hematology
233 85002 Laboratory - Chemistry And Hematology
233 85004 Laboratory - Chemistry And Hematology
233 85007 Laboratory - Chemistry And Hematology
233 85008 Laboratory - Chemistry And Hematology
233 85009 Laboratory - Chemistry And Hematology
233 85013 Laboratory - Chemistry And Hematology
233 85014 Laboratory - Chemistry And Hematology
233 85018 Laboratory - Chemistry And Hematology
233 85025 Laboratory - Chemistry And Hematology
233 85027 Laboratory - Chemistry And Hematology
233 85032 Laboratory - Chemistry And Hematology
233 85041 Laboratory - Chemistry And Hematology
233 85044 Laboratory - Chemistry And Hematology
233 85045 Laboratory - Chemistry And Hematology
233 85046 Laboratory - Chemistry And Hematology
233 85048 Laboratory - Chemistry And Hematology
233 85049 Laboratory - Chemistry And Hematology
233 85055 Laboratory - Chemistry And Hematology
233 85060 Laboratory - Chemistry And Hematology
206 85097 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
233 85130 Laboratory - Chemistry And Hematology
233 85170 Laboratory - Chemistry And Hematology
233 85175 Laboratory - Chemistry And Hematology
233 85210 Laboratory - Chemistry And Hematology
233 85220 Laboratory - Chemistry And Hematology
233 85230 Laboratory - Chemistry And Hematology
233 85240 Laboratory - Chemistry And Hematology
233 85244 Laboratory - Chemistry And Hematology
233 85245 Laboratory - Chemistry And Hematology
233 85246 Laboratory - Chemistry And Hematology
233 85247 Laboratory - Chemistry And Hematology
233 85250 Laboratory - Chemistry And Hematology
233 85260 Laboratory - Chemistry And Hematology
233 85270 Laboratory - Chemistry And Hematology
233 85280 Laboratory - Chemistry And Hematology
233 85290 Laboratory - Chemistry And Hematology
233 85291 Laboratory - Chemistry And Hematology
233 85292 Laboratory - Chemistry And Hematology
233 85293 Laboratory - Chemistry And Hematology
233 85300 Laboratory - Chemistry And Hematology
233 85301 Laboratory - Chemistry And Hematology
Blue Cross NC Proprietary and Confidential 99 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
233 85302 Laboratory - Chemistry And Hematology
233 85303 Laboratory - Chemistry And Hematology
233 85305 Laboratory - Chemistry And Hematology
233 85306 Laboratory - Chemistry And Hematology
233 85307 Laboratory - Chemistry And Hematology
233 85335 Laboratory - Chemistry And Hematology
233 85337 Laboratory - Chemistry And Hematology
233 85345 Laboratory - Chemistry And Hematology
233 85347 Laboratory - Chemistry And Hematology
233 85348 Laboratory - Chemistry And Hematology
233 85360 Laboratory - Chemistry And Hematology
233 85362 Laboratory - Chemistry And Hematology
233 85366 Laboratory - Chemistry And Hematology
233 85370 Laboratory - Chemistry And Hematology
233 85378 Laboratory - Chemistry And Hematology
233 85379 Laboratory - Chemistry And Hematology
233 85380 Laboratory - Chemistry And Hematology
233 85384 Laboratory - Chemistry And Hematology
233 85385 Laboratory - Chemistry And Hematology
233 85390 Laboratory - Chemistry And Hematology
233 85396 Laboratory - Chemistry And Hematology
233 85397 Laboratory - Chemistry And Hematology
233 85400 Laboratory - Chemistry And Hematology
233 85410 Laboratory - Chemistry And Hematology
233 85415 Laboratory - Chemistry And Hematology
233 85420 Laboratory - Chemistry And Hematology
233 85421 Laboratory - Chemistry And Hematology
233 85441 Laboratory - Chemistry And Hematology
233 85445 Laboratory - Chemistry And Hematology
233 85460 Laboratory - Chemistry And Hematology
233 85461 Laboratory - Chemistry And Hematology
233 85475 Laboratory - Chemistry And Hematology
233 85520 Laboratory - Chemistry And Hematology
233 85525 Laboratory - Chemistry And Hematology
233 85530 Laboratory - Chemistry And Hematology
233 85536 Laboratory - Chemistry And Hematology
233 85540 Laboratory - Chemistry And Hematology
233 85547 Laboratory - Chemistry And Hematology
233 85549 Laboratory - Chemistry And Hematology
233 85555 Laboratory - Chemistry And Hematology
233 85557 Laboratory - Chemistry And Hematology
233 85576 Laboratory - Chemistry And Hematology
233 85597 Laboratory - Chemistry And Hematology
233 85598 Laboratory - Chemistry And Hematology
233 85610 Laboratory - Chemistry And Hematology
233 85611 Laboratory - Chemistry And Hematology
233 85612 Laboratory - Chemistry And Hematology
233 85613 Laboratory - Chemistry And Hematology
233 85635 Laboratory - Chemistry And Hematology
233 85651 Laboratory - Chemistry And Hematology
233 85652 Laboratory - Chemistry And Hematology
233 85660 Laboratory - Chemistry And Hematology
233 85670 Laboratory - Chemistry And Hematology
233 85675 Laboratory - Chemistry And Hematology
233 85705 Laboratory - Chemistry And Hematology
233 85730 Laboratory - Chemistry And Hematology
233 85732 Laboratory - Chemistry And Hematology
233 85810 Laboratory - Chemistry And Hematology
233 85999 Laboratory - Chemistry And Hematology
235 86000 Other Laboratory
235 86001 Other Laboratory
235 86003 Other Laboratory
235 86005 Other Laboratory
235 86008 Other Laboratory
235 86021 Other Laboratory
235 86022 Other Laboratory
235 86023 Other Laboratory
235 86038 Other Laboratory
235 86039 Other Laboratory
235 86060 Other Laboratory
235 86063 Other Laboratory
227 86077 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 86078 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 86079 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
Blue Cross NC Proprietary and Confidential 100 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
235 86140 Other Laboratory
235 86141 Other Laboratory
235 86146 Other Laboratory
235 86147 Other Laboratory
235 86148 Other Laboratory
235 86152 Other Laboratory
235 86155 Other Laboratory
235 86156 Other Laboratory
235 86157 Other Laboratory
235 86160 Other Laboratory
235 86161 Other Laboratory
235 86162 Other Laboratory
235 86171 Other Laboratory
235 86200 Other Laboratory
235 86215 Other Laboratory
235 86225 Other Laboratory
235 86226 Other Laboratory
235 86235 Other Laboratory
235 86255 Other Laboratory
235 86256 Other Laboratory
235 86277 Other Laboratory
235 86280 Other Laboratory
235 86294 Other Laboratory
235 86300 Other Laboratory
235 86301 Other Laboratory
235 86304 Other Laboratory
235 86305 Other Laboratory
235 86308 Other Laboratory
235 86309 Other Laboratory
235 86310 Other Laboratory
235 86316 Other Laboratory
235 86317 Other Laboratory
235 86318 Other Laboratory
235 86320 Other Laboratory
235 86325 Other Laboratory
235 86327 Other Laboratory
206 86328 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
235 86329 Other Laboratory
235 86331 Other Laboratory
235 86332 Other Laboratory
235 86334 Other Laboratory
235 86335 Other Laboratory
235 86336 Other Laboratory
235 86337 Other Laboratory
235 86340 Other Laboratory
235 86341 Other Laboratory
235 86343 Other Laboratory
235 86344 Other Laboratory
235 86352 Other Laboratory
235 86353 Other Laboratory
235 86355 Other Laboratory
235 86356 Other Laboratory
235 86357 Other Laboratory
235 86359 Other Laboratory
235 86360 Other Laboratory
235 86361 Other Laboratory
235 86367 Other Laboratory
235 86376 Other Laboratory
235 86382 Other Laboratory
235 86384 Other Laboratory
235 86386 Other Laboratory
235 86403 Other Laboratory
235 86406 Other Laboratory
235 86430 Other Laboratory
235 86431 Other Laboratory
235 86480 Other Laboratory
235 86481 Other Laboratory
235 86485 Other Laboratory
235 86486 Other Laboratory
235 86490 Other Laboratory
235 86510 Other Laboratory
235 86580 Other Laboratory
235 86590 Other Laboratory
235 86592 Other Laboratory
Blue Cross NC Proprietary and Confidential 101 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
235 86593 Other Laboratory
235 86602 Other Laboratory
235 86603 Other Laboratory
235 86606 Other Laboratory
235 86609 Other Laboratory
235 86611 Other Laboratory
235 86612 Other Laboratory
235 86615 Other Laboratory
235 86617 Other Laboratory
235 86618 Other Laboratory
235 86619 Other Laboratory
235 86622 Other Laboratory
235 86625 Other Laboratory
235 86628 Other Laboratory
235 86631 Other Laboratory
235 86632 Other Laboratory
235 86635 Other Laboratory
235 86638 Other Laboratory
235 86641 Other Laboratory
235 86644 Other Laboratory
235 86645 Other Laboratory
235 86648 Other Laboratory
235 86651 Other Laboratory
235 86652 Other Laboratory
235 86653 Other Laboratory
235 86654 Other Laboratory
235 86658 Other Laboratory
235 86663 Other Laboratory
235 86664 Other Laboratory
235 86665 Other Laboratory
235 86666 Other Laboratory
235 86668 Other Laboratory
235 86671 Other Laboratory
235 86674 Other Laboratory
235 86677 Other Laboratory
235 86682 Other Laboratory
235 86684 Other Laboratory
235 86687 Other Laboratory
235 86688 Other Laboratory
235 86689 Other Laboratory
235 86692 Other Laboratory
235 86694 Other Laboratory
235 86695 Other Laboratory
235 86696 Other Laboratory
235 86698 Other Laboratory
235 86701 Other Laboratory
235 86702 Other Laboratory
235 86703 Other Laboratory
235 86704 Other Laboratory
235 86705 Other Laboratory
235 86706 Other Laboratory
235 86707 Other Laboratory
235 86708 Other Laboratory
235 86709 Other Laboratory
235 86710 Other Laboratory
235 86711 Other Laboratory
235 86713 Other Laboratory
235 86717 Other Laboratory
235 86720 Other Laboratory
235 86723 Other Laboratory
235 86727 Other Laboratory
235 86732 Other Laboratory
235 86735 Other Laboratory
235 86738 Other Laboratory
235 86741 Other Laboratory
235 86744 Other Laboratory
235 86747 Other Laboratory
235 86750 Other Laboratory
235 86753 Other Laboratory
235 86756 Other Laboratory
235 86757 Other Laboratory
235 86759 Other Laboratory
235 86762 Other Laboratory
235 86765 Other Laboratory
Blue Cross NC Proprietary and Confidential 102 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
235 86768 Other Laboratory
206 86769 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
235 86771 Other Laboratory
235 86774 Other Laboratory
235 86777 Other Laboratory
235 86778 Other Laboratory
235 86780 Other Laboratory
235 86784 Other Laboratory
235 86787 Other Laboratory
235 86788 Other Laboratory
235 86789 Other Laboratory
235 86790 Other Laboratory
235 86793 Other Laboratory
235 86794 Other Laboratory
235 86800 Other Laboratory
235 86803 Other Laboratory
235 86804 Other Laboratory
235 86805 Other Laboratory
235 86806 Other Laboratory
235 86807 Other Laboratory
235 86808 Other Laboratory
206 86812 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 86813 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 86816 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 86817 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 86821 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 86825 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 86826 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
235 86828 Other Laboratory
235 86829 Other Laboratory
235 86830 Other Laboratory
235 86831 Other Laboratory
235 86832 Other Laboratory
235 86833 Other Laboratory
235 86834 Other Laboratory
235 86835 Other Laboratory
235 86849 Other Laboratory
235 86850 Other Laboratory
235 86860 Other Laboratory
235 86870 Other Laboratory
235 86880 Other Laboratory
235 86885 Other Laboratory
235 86886 Other Laboratory
235 86890 Other Laboratory
235 86891 Other Laboratory
235 86900 Other Laboratory
235 86901 Other Laboratory
235 86902 Other Laboratory
235 86904 Other Laboratory
235 86905 Other Laboratory
235 86906 Other Laboratory
235 86910 Other Laboratory
235 86911 Other Laboratory
235 86920 Other Laboratory
235 86921 Other Laboratory
235 86922 Other Laboratory
235 86923 Other Laboratory
235 86927 Other Laboratory
235 86930 Other Laboratory
235 86931 Other Laboratory
235 86932 Other Laboratory
235 86940 Other Laboratory
235 86941 Other Laboratory
235 86945 Other Laboratory
235 86950 Other Laboratory
235 86960 Other Laboratory
235 86965 Other Laboratory
235 86970 Other Laboratory
235 86971 Other Laboratory
235 86972 Other Laboratory
235 86975 Other Laboratory
235 86976 Other Laboratory
235 86977 Other Laboratory
235 86978 Other Laboratory
Blue Cross NC Proprietary and Confidential 103 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
235 86985 Other Laboratory
235 86999 Other Laboratory
235 87003 Other Laboratory
206 87015 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87040 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87045 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87046 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87070 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87071 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87073 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87075 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87076 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87077 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87081 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87084 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87086 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87088 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87101 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87102 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87103 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87106 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87107 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87109 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87110 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87116 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87118 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87140 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87143 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87147 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87149 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87150 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87152 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87153 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87158 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87164 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87166 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87168 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87169 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87172 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87176 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87177 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87181 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87184 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87185 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87186 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87187 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87188 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87190 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87197 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87205 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87206 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87207 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
235 87209 Other Laboratory
206 87210 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87220 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87230 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87250 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87252 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87253 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87254 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87255 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87260 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87265 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87267 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87269 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87270 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87271 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87272 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87273 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87274 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87275 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87276 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87278 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87279 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
Blue Cross NC Proprietary and Confidential 104 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
206 87280 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87281 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87283 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87285 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87290 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87299 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87300 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87301 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87305 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87320 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87324 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87327 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87328 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87329 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87332 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87335 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87336 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87337 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87338 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87339 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87340 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87341 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87350 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87380 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87385 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87389 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87390 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87391 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87400 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87420 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87425 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87427 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87430 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87449 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87450 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87451 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87471 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87472 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87475 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87476 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87480 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87481 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87482 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87483 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87485 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87486 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87487 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87490 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87491 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87492 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
235 87493 Other Laboratory
206 87495 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87496 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87497 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87498 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87500 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87501 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87502 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87503 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87505 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87506 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87507 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87510 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87511 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87512 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87516 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87517 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87520 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87521 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87522 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87525 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87526 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87527 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87528 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
Blue Cross NC Proprietary and Confidential 105 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
206 87529 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87530 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87531 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87532 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87533 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87534 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87535 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87536 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87537 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87538 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87539 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87540 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87541 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87542 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87550 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87551 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87552 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87555 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87556 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87557 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87560 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87561 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87562 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
234 87563 Pathology
206 87580 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87581 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87582 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87590 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87591 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87592 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87623 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87624 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87625 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87631 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87632 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87633 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87634 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
234 87635 Pathology
206 87640 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87641 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87650 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87651 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87652 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87653 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87660 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87661 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87662 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87797 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87798 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87799 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87800 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87801 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87802 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87803 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87804 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87806 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87807 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87808 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87809 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87810 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87850 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87880 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87899 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87900 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87901 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87902 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87903 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87904 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87905 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87906 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87910 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87912 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 87999 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
234 88000 Pathology
Blue Cross NC Proprietary and Confidential 106 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
234 88005 Pathology
234 88007 Pathology
234 88012 Pathology
234 88014 Pathology
234 88016 Pathology
234 88020 Pathology
234 88025 Pathology
234 88027 Pathology
234 88028 Pathology
234 88029 Pathology
234 88036 Pathology
234 88037 Pathology
234 88040 Pathology
234 88045 Pathology
234 88099 Pathology
234 88104 Pathology
234 88106 Pathology
234 88108 Pathology
234 88112 Pathology
234 88120 Pathology
234 88121 Pathology
234 88125 Pathology
234 88130 Pathology
234 88140 Pathology
234 88141 Pathology
234 88142 Pathology
234 88143 Pathology
234 88147 Pathology
234 88148 Pathology
234 88150 Pathology
234 88152 Pathology
234 88153 Pathology
234 88155 Pathology
234 88160 Pathology
234 88161 Pathology
234 88162 Pathology
234 88164 Pathology
234 88165 Pathology
234 88166 Pathology
234 88167 Pathology
234 88172 Pathology
234 88173 Pathology
234 88174 Pathology
234 88175 Pathology
234 88177 Pathology
234 88182 Pathology
234 88184 Pathology
234 88185 Pathology
234 88187 Pathology
234 88188 Pathology
234 88189 Pathology
234 88199 Pathology
206 88230 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 88233 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 88235 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 88237 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 88239 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
235 88240 Other Laboratory
235 88241 Other Laboratory
206 88245 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 88248 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 88249 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 88261 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 88262 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 88263 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 88264 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 88267 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 88269 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
235 88271 Other Laboratory
235 88272 Other Laboratory
235 88273 Other Laboratory
235 88274 Other Laboratory
235 88275 Other Laboratory
206 88280 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
Blue Cross NC Proprietary and Confidential 107 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
206 88283 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 88285 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 88289 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 88291 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 88299 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
234 88300 Pathology
234 88302 Pathology
234 88304 Pathology
234 88305 Pathology
234 88307 Pathology
234 88309 Pathology
234 88311 Pathology
234 88312 Pathology
234 88313 Pathology
234 88314 Pathology
233 88319 Laboratory - Chemistry And Hematology
234 88321 Pathology
234 88323 Pathology
227 88325 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
234 88329 Pathology
234 88331 Pathology
234 88332 Pathology
234 88333 Pathology
234 88334 Pathology
234 88341 Pathology
234 88342 Pathology
234 88344 Pathology
234 88346 Pathology
234 88348 Pathology
234 88350 Pathology
234 88355 Pathology
234 88356 Pathology
234 88358 Pathology
234 88360 Pathology
234 88361 Pathology
234 88362 Pathology
234 88363 Pathology
234 88364 Pathology
234 88365 Pathology
234 88366 Pathology
234 88367 Pathology
234 88368 Pathology
234 88369 Pathology
234 88371 Pathology
234 88372 Pathology
234 88373 Pathology
234 88374 Pathology
234 88375 Pathology
234 88377 Pathology
234 88380 Pathology
234 88381 Pathology
234 88387 Pathology
234 88388 Pathology
234 88399 Pathology
235 88720 Other Laboratory
233 88738 Laboratory - Chemistry And Hematology
233 88740 Laboratory - Chemistry And Hematology
233 88741 Laboratory - Chemistry And Hematology
235 88749 Other Laboratory
235 89049 Other Laboratory
235 89050 Other Laboratory
235 89051 Other Laboratory
235 89055 Other Laboratory
206 89060 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 89125 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 89160 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 89190 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 89220 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 89230 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
234 89240 Pathology
206 89250 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 89251 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 89253 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 89254 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
Blue Cross NC Proprietary and Confidential 108 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
206 89255 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 89257 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
235 89258 Other Laboratory
235 89259 Other Laboratory
206 89260 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 89261 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 89264 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 89268 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 89272 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 89280 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 89281 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 89290 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 89291 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 89300 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 89310 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 89320 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 89321 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 89322 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 89325 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 89329 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 89330 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 89331 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
235 89335 Other Laboratory
235 89337 Other Laboratory
235 89342 Other Laboratory
235 89343 Other Laboratory
235 89344 Other Laboratory
235 89346 Other Laboratory
235 89352 Other Laboratory
235 89353 Other Laboratory
235 89354 Other Laboratory
235 89356 Other Laboratory
235 89398 Other Laboratory
228 90281 Prophylactic vaccinations and inoculations
228 90283 Prophylactic vaccinations and inoculations
228 90284 Prophylactic vaccinations and inoculations
228 90287 Prophylactic vaccinations and inoculations
228 90288 Prophylactic vaccinations and inoculations
228 90291 Prophylactic vaccinations and inoculations
228 90296 Prophylactic vaccinations and inoculations
228 90371 Prophylactic vaccinations and inoculations
228 90375 Prophylactic vaccinations and inoculations
228 90376 Prophylactic vaccinations and inoculations
228 90378 Prophylactic vaccinations and inoculations
228 90384 Prophylactic vaccinations and inoculations
228 90385 Prophylactic vaccinations and inoculations
228 90386 Prophylactic vaccinations and inoculations
228 90389 Prophylactic vaccinations and inoculations
228 90393 Prophylactic vaccinations and inoculations
228 90396 Prophylactic vaccinations and inoculations
228 90399 Prophylactic vaccinations and inoculations
O1G 90460 Immunizations/Vaccinations
O1G 90461 Immunizations/Vaccinations
O1G 90471 Immunizations/Vaccinations
O1G 90472 Immunizations/Vaccinations
O1G 90473 Immunizations/Vaccinations
O1G 90474 Immunizations/Vaccinations
228 90476 Prophylactic vaccinations and inoculations
228 90477 Prophylactic vaccinations and inoculations
228 90581 Prophylactic vaccinations and inoculations
228 90585 Prophylactic vaccinations and inoculations
228 90586 Prophylactic vaccinations and inoculations
228 90587 Prophylactic vaccinations and inoculations
228 90619 Prophylactic vaccinations and inoculations
228 90620 Prophylactic vaccinations and inoculations
228 90621 Prophylactic vaccinations and inoculations
228 90625 Prophylactic vaccinations and inoculations
228 90630 Prophylactic vaccinations and inoculations
228 90632 Prophylactic vaccinations and inoculations
228 90633 Prophylactic vaccinations and inoculations
228 90634 Prophylactic vaccinations and inoculations
228 90636 Prophylactic vaccinations and inoculations
228 90644 Prophylactic vaccinations and inoculations
228 90647 Prophylactic vaccinations and inoculations
Blue Cross NC Proprietary and Confidential 109 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
228 90648 Prophylactic vaccinations and inoculations
228 90649 Prophylactic vaccinations and inoculations
228 90650 Prophylactic vaccinations and inoculations
228 90651 Prophylactic vaccinations and inoculations
228 90653 Prophylactic vaccinations and inoculations
228 90654 Prophylactic vaccinations and inoculations
228 90655 Prophylactic vaccinations and inoculations
228 90656 Prophylactic vaccinations and inoculations
228 90657 Prophylactic vaccinations and inoculations
228 90658 Prophylactic vaccinations and inoculations
228 90660 Prophylactic vaccinations and inoculations
228 90661 Prophylactic vaccinations and inoculations
228 90662 Prophylactic vaccinations and inoculations
228 90668 Prophylactic vaccinations and inoculations
228 90670 Prophylactic vaccinations and inoculations
228 90672 Prophylactic vaccinations and inoculations
228 90673 Prophylactic vaccinations and inoculations
228 90674 Prophylactic vaccinations and inoculations
228 90675 Prophylactic vaccinations and inoculations
228 90676 Prophylactic vaccinations and inoculations
228 90680 Prophylactic vaccinations and inoculations
228 90681 Prophylactic vaccinations and inoculations
228 90682 Prophylactic vaccinations and inoculations
228 90685 Prophylactic vaccinations and inoculations
228 90686 Prophylactic vaccinations and inoculations
228 90687 Prophylactic vaccinations and inoculations
228 90688 Prophylactic vaccinations and inoculations
228 90689 Prophylactic vaccinations and inoculations
228 90690 Prophylactic vaccinations and inoculations
228 90691 Prophylactic vaccinations and inoculations
O1G 90694 Immunizations/Vaccinations
228 90696 Prophylactic vaccinations and inoculations
228 90697 Prophylactic vaccinations and inoculations
228 90698 Prophylactic vaccinations and inoculations
228 90700 Prophylactic vaccinations and inoculations
228 90702 Prophylactic vaccinations and inoculations
228 90707 Prophylactic vaccinations and inoculations
228 90710 Prophylactic vaccinations and inoculations
228 90713 Prophylactic vaccinations and inoculations
228 90714 Prophylactic vaccinations and inoculations
228 90715 Prophylactic vaccinations and inoculations
228 90716 Prophylactic vaccinations and inoculations
228 90717 Prophylactic vaccinations and inoculations
228 90723 Prophylactic vaccinations and inoculations
228 90732 Prophylactic vaccinations and inoculations
228 90733 Prophylactic vaccinations and inoculations
228 90734 Prophylactic vaccinations and inoculations
228 90736 Prophylactic vaccinations and inoculations
228 90738 Prophylactic vaccinations and inoculations
228 90739 Prophylactic vaccinations and inoculations
228 90740 Prophylactic vaccinations and inoculations
228 90743 Prophylactic vaccinations and inoculations
228 90744 Prophylactic vaccinations and inoculations
228 90746 Prophylactic vaccinations and inoculations
228 90747 Prophylactic vaccinations and inoculations
228 90748 Prophylactic vaccinations and inoculations
228 90749 Prophylactic vaccinations and inoculations
228 90750 Prophylactic vaccinations and inoculations
228 90756 Prophylactic vaccinations and inoculations
218 90785 Psychological And Psychiatric Evaluation And Therapy
218 90791 Psychological And Psychiatric Evaluation And Therapy
218 90792 Psychological And Psychiatric Evaluation And Therapy
218 90832 Psychological And Psychiatric Evaluation And Therapy
218 90833 Psychological And Psychiatric Evaluation And Therapy
218 90834 Psychological And Psychiatric Evaluation And Therapy
218 90836 Psychological And Psychiatric Evaluation And Therapy
218 90837 Psychological And Psychiatric Evaluation And Therapy
218 90838 Psychological And Psychiatric Evaluation And Therapy
218 90839 Psychological And Psychiatric Evaluation And Therapy
218 90840 Psychological And Psychiatric Evaluation And Therapy
218 90845 Psychological And Psychiatric Evaluation And Therapy
218 90846 Psychological And Psychiatric Evaluation And Therapy
218 90847 Psychological And Psychiatric Evaluation And Therapy
218 90849 Psychological And Psychiatric Evaluation And Therapy
Blue Cross NC Proprietary and Confidential 110 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
218 90853 Psychological And Psychiatric Evaluation And Therapy
218 90863 Psychological And Psychiatric Evaluation And Therapy
218 90865 Psychological And Psychiatric Evaluation And Therapy
218 90867 Psychological And Psychiatric Evaluation And Therapy
218 90868 Psychological And Psychiatric Evaluation And Therapy
218 90869 Psychological And Psychiatric Evaluation And Therapy
218 90870 Psychological And Psychiatric Evaluation And Therapy
218 90875 Psychological And Psychiatric Evaluation And Therapy
218 90876 Psychological And Psychiatric Evaluation And Therapy
218 90880 Psychological And Psychiatric Evaluation And Therapy
218 90882 Psychological And Psychiatric Evaluation And Therapy
218 90885 Psychological And Psychiatric Evaluation And Therapy
218 90887 Psychological And Psychiatric Evaluation And Therapy
218 90889 Psychological And Psychiatric Evaluation And Therapy
218 90899 Psychological And Psychiatric Evaluation And Therapy
213 90901 Physical Therapy Exercises, Manipulation, And Other Procedures
215 90912 Other Physical Therapy And Rehabilitation
215 90913 Other Physical Therapy And Rehabilitation
58 90935 Hemodialysis
58 90937 Hemodialysis
58 90940 Hemodialysis
91 90945 Peritoneal Dialysis
91 90947 Peritoneal Dialysis
227 90951 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 90952 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 90953 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 90954 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 90955 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 90956 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 90957 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 90958 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 90959 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 90960 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 90961 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 90962 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 90963 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 90964 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 90965 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 90966 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 90967 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 90968 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 90969 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 90970 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
91 90989 Peritoneal Dialysis
91 90993 Peritoneal Dialysis
91 90997 Peritoneal Dialysis
91 90999 Peritoneal Dialysis
97 91010 Other Gastrointestinal Diagnostic Procedures
97 91013 Other Gastrointestinal Diagnostic Procedures
97 91020 Other Gastrointestinal Diagnostic Procedures
97 91022 Other Gastrointestinal Diagnostic Procedures
97 91030 Other Gastrointestinal Diagnostic Procedures
97 91034 Other Gastrointestinal Diagnostic Procedures
97 91035 Other Gastrointestinal Diagnostic Procedures
97 91037 Other Gastrointestinal Diagnostic Procedures
97 91038 Other Gastrointestinal Diagnostic Procedures
97 91040 Other Gastrointestinal Diagnostic Procedures
97 91065 Other Gastrointestinal Diagnostic Procedures
98 91110 Other Non-Or Gastrointestinal Therapeutic Procedures
98 91111 Other Non-Or Gastrointestinal Therapeutic Procedures
97 91112 Other Gastrointestinal Diagnostic Procedures
97 91117 Other Gastrointestinal Diagnostic Procedures
97 91120 Other Gastrointestinal Diagnostic Procedures
97 91122 Other Gastrointestinal Diagnostic Procedures
97 91132 Other Gastrointestinal Diagnostic Procedures
97 91133 Other Gastrointestinal Diagnostic Procedures
97 91200 Other Gastrointestinal Diagnostic Procedures
97 91299 Other Gastrointestinal Diagnostic Procedures
CEC 92002 Ophthalmologic And Otologic Diagnosis And Treatment
CEC 92004 Ophthalmologic And Otologic Diagnosis And Treatment
CEC 92012 Ophthalmologic And Otologic Diagnosis And Treatment
CEC 92014 Ophthalmologic And Otologic Diagnosis And Treatment
220 92015 Ophthalmologic And Otologic Diagnosis And Treatment
220 92018 Ophthalmologic And Otologic Diagnosis And Treatment
Blue Cross NC Proprietary and Confidential 111 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
220 92019 Ophthalmologic And Otologic Diagnosis And Treatment
220 92020 Ophthalmologic And Otologic Diagnosis And Treatment
220 92025 Ophthalmologic And Otologic Diagnosis And Treatment
220 92060 Ophthalmologic And Otologic Diagnosis And Treatment
220 92065 Ophthalmologic And Otologic Diagnosis And Treatment
220 92071 Ophthalmologic And Otologic Diagnosis And Treatment
220 92072 Ophthalmologic And Otologic Diagnosis And Treatment
220 92081 Ophthalmologic And Otologic Diagnosis And Treatment
220 92082 Ophthalmologic And Otologic Diagnosis And Treatment
220 92083 Ophthalmologic And Otologic Diagnosis And Treatment
220 92100 Ophthalmologic And Otologic Diagnosis And Treatment
220 92132 Ophthalmologic And Otologic Diagnosis And Treatment
220 92133 Ophthalmologic And Otologic Diagnosis And Treatment
220 92134 Ophthalmologic And Otologic Diagnosis And Treatment
220 92136 Ophthalmologic And Otologic Diagnosis And Treatment
220 92145 Ophthalmologic And Otologic Diagnosis And Treatment
18 92201 Diagnostic Procedures On Eye
18 92202 Diagnostic Procedures On Eye
220 92227 Ophthalmologic And Otologic Diagnosis And Treatment
220 92228 Ophthalmologic And Otologic Diagnosis And Treatment
220 92230 Ophthalmologic And Otologic Diagnosis And Treatment
220 92235 Ophthalmologic And Otologic Diagnosis And Treatment
220 92240 Ophthalmologic And Otologic Diagnosis And Treatment
220 92242 Ophthalmologic And Otologic Diagnosis And Treatment
220 92250 Ophthalmologic And Otologic Diagnosis And Treatment
220 92260 Ophthalmologic And Otologic Diagnosis And Treatment
220 92265 Ophthalmologic And Otologic Diagnosis And Treatment
220 92270 Ophthalmologic And Otologic Diagnosis And Treatment
18 92273 Diagnostic Procedures On Eye
18 92274 Diagnostic Procedures On Eye
220 92283 Ophthalmologic And Otologic Diagnosis And Treatment
220 92284 Ophthalmologic And Otologic Diagnosis And Treatment
220 92285 Ophthalmologic And Otologic Diagnosis And Treatment
220 92286 Ophthalmologic And Otologic Diagnosis And Treatment
220 92287 Ophthalmologic And Otologic Diagnosis And Treatment
220 92310 Ophthalmologic And Otologic Diagnosis And Treatment
220 92311 Ophthalmologic And Otologic Diagnosis And Treatment
220 92312 Ophthalmologic And Otologic Diagnosis And Treatment
220 92313 Ophthalmologic And Otologic Diagnosis And Treatment
220 92314 Ophthalmologic And Otologic Diagnosis And Treatment
220 92315 Ophthalmologic And Otologic Diagnosis And Treatment
220 92316 Ophthalmologic And Otologic Diagnosis And Treatment
220 92317 Ophthalmologic And Otologic Diagnosis And Treatment
220 92325 Ophthalmologic And Otologic Diagnosis And Treatment
220 92326 Ophthalmologic And Otologic Diagnosis And Treatment
220 92340 Ophthalmologic And Otologic Diagnosis And Treatment
220 92341 Ophthalmologic And Otologic Diagnosis And Treatment
220 92342 Ophthalmologic And Otologic Diagnosis And Treatment
220 92352 Ophthalmologic And Otologic Diagnosis And Treatment
220 92353 Ophthalmologic And Otologic Diagnosis And Treatment
220 92354 Ophthalmologic And Otologic Diagnosis And Treatment
220 92355 Ophthalmologic And Otologic Diagnosis And Treatment
220 92358 Ophthalmologic And Otologic Diagnosis And Treatment
220 92370 Ophthalmologic And Otologic Diagnosis And Treatment
220 92371 Ophthalmologic And Otologic Diagnosis And Treatment
220 92499 Ophthalmologic And Otologic Diagnosis And Treatment
31 92502 Diagnostic Procedures On Nose, Mouth And Pharynx
31 92504 Diagnostic Procedures On Nose, Mouth And Pharynx
215 92507 Other Physical Therapy And Rehabilitation
215 92508 Other Physical Therapy And Rehabilitation
31 92511 Diagnostic Procedures On Nose, Mouth And Pharynx
31 92512 Diagnostic Procedures On Nose, Mouth And Pharynx
7 92516 Other Diagnostic Nervous System Procedures
40 92520 Other Diagnostic Procedures Of Respiratory Tract And Mediastinum
227 92521 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 92522 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 92523 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 92524 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
231 92526 Other Therapeutic Procedures
220 92531 Ophthalmologic And Otologic Diagnosis And Treatment
220 92532 Ophthalmologic And Otologic Diagnosis And Treatment
220 92533 Ophthalmologic And Otologic Diagnosis And Treatment
220 92534 Ophthalmologic And Otologic Diagnosis And Treatment
220 92537 Ophthalmologic And Otologic Diagnosis And Treatment
Blue Cross NC Proprietary and Confidential 112 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
220 92538 Ophthalmologic And Otologic Diagnosis And Treatment
220 92540 Ophthalmologic And Otologic Diagnosis And Treatment
220 92541 Ophthalmologic And Otologic Diagnosis And Treatment
220 92542 Ophthalmologic And Otologic Diagnosis And Treatment
220 92544 Ophthalmologic And Otologic Diagnosis And Treatment
220 92545 Ophthalmologic And Otologic Diagnosis And Treatment
220 92546 Ophthalmologic And Otologic Diagnosis And Treatment
220 92547 Ophthalmologic And Otologic Diagnosis And Treatment
227 92548 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
7 92549 Other Diagnostic Nervous System Procedures
220 92550 Ophthalmologic And Otologic Diagnosis And Treatment
220 92551 Ophthalmologic And Otologic Diagnosis And Treatment
220 92552 Ophthalmologic And Otologic Diagnosis And Treatment
220 92553 Ophthalmologic And Otologic Diagnosis And Treatment
220 92555 Ophthalmologic And Otologic Diagnosis And Treatment
220 92556 Ophthalmologic And Otologic Diagnosis And Treatment
220 92557 Ophthalmologic And Otologic Diagnosis And Treatment
220 92558 Ophthalmologic And Otologic Diagnosis And Treatment
220 92559 Ophthalmologic And Otologic Diagnosis And Treatment
220 92560 Ophthalmologic And Otologic Diagnosis And Treatment
220 92561 Ophthalmologic And Otologic Diagnosis And Treatment
220 92562 Ophthalmologic And Otologic Diagnosis And Treatment
220 92563 Ophthalmologic And Otologic Diagnosis And Treatment
220 92564 Ophthalmologic And Otologic Diagnosis And Treatment
220 92565 Ophthalmologic And Otologic Diagnosis And Treatment
220 92567 Ophthalmologic And Otologic Diagnosis And Treatment
220 92568 Ophthalmologic And Otologic Diagnosis And Treatment
220 92570 Ophthalmologic And Otologic Diagnosis And Treatment
220 92571 Ophthalmologic And Otologic Diagnosis And Treatment
220 92572 Ophthalmologic And Otologic Diagnosis And Treatment
220 92575 Ophthalmologic And Otologic Diagnosis And Treatment
220 92576 Ophthalmologic And Otologic Diagnosis And Treatment
220 92577 Ophthalmologic And Otologic Diagnosis And Treatment
220 92579 Ophthalmologic And Otologic Diagnosis And Treatment
220 92582 Ophthalmologic And Otologic Diagnosis And Treatment
220 92583 Ophthalmologic And Otologic Diagnosis And Treatment
220 92584 Ophthalmologic And Otologic Diagnosis And Treatment
220 92585 Ophthalmologic And Otologic Diagnosis And Treatment
220 92586 Ophthalmologic And Otologic Diagnosis And Treatment
220 92587 Ophthalmologic And Otologic Diagnosis And Treatment
220 92588 Ophthalmologic And Otologic Diagnosis And Treatment
220 92590 Ophthalmologic And Otologic Diagnosis And Treatment
220 92591 Ophthalmologic And Otologic Diagnosis And Treatment
220 92592 Ophthalmologic And Otologic Diagnosis And Treatment
220 92593 Ophthalmologic And Otologic Diagnosis And Treatment
220 92594 Ophthalmologic And Otologic Diagnosis And Treatment
220 92595 Ophthalmologic And Otologic Diagnosis And Treatment
220 92596 Ophthalmologic And Otologic Diagnosis And Treatment
215 92597 Other Physical Therapy And Rehabilitation
220 92601 Ophthalmologic And Otologic Diagnosis And Treatment
220 92602 Ophthalmologic And Otologic Diagnosis And Treatment
220 92603 Ophthalmologic And Otologic Diagnosis And Treatment
220 92604 Ophthalmologic And Otologic Diagnosis And Treatment
220 92605 Ophthalmologic And Otologic Diagnosis And Treatment
220 92606 Ophthalmologic And Otologic Diagnosis And Treatment
220 92607 Ophthalmologic And Otologic Diagnosis And Treatment
220 92608 Ophthalmologic And Otologic Diagnosis And Treatment
220 92609 Ophthalmologic And Otologic Diagnosis And Treatment
31 92610 Diagnostic Procedures On Nose, Mouth And Pharynx
31 92611 Diagnostic Procedures On Nose, Mouth And Pharynx
31 92612 Diagnostic Procedures On Nose, Mouth And Pharynx
31 92613 Diagnostic Procedures On Nose, Mouth And Pharynx
31 92614 Diagnostic Procedures On Nose, Mouth And Pharynx
31 92615 Diagnostic Procedures On Nose, Mouth And Pharynx
31 92616 Diagnostic Procedures On Nose, Mouth And Pharynx
31 92617 Diagnostic Procedures On Nose, Mouth And Pharynx
220 92618 Ophthalmologic And Otologic Diagnosis And Treatment
220 92620 Ophthalmologic And Otologic Diagnosis And Treatment
220 92621 Ophthalmologic And Otologic Diagnosis And Treatment
220 92625 Ophthalmologic And Otologic Diagnosis And Treatment
25 92626 Diagnostic Procedures On Ear
25 92627 Diagnostic Procedures On Ear
25 92630 Diagnostic Procedures On Ear
25 92633 Diagnostic Procedures On Ear
Blue Cross NC Proprietary and Confidential 113 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
25 92640 Diagnostic Procedures On Ear
31 92700 Diagnostic Procedures On Nose, Mouth And Pharynx
45 92920 Percutaneous Transluminal Coronary Angioplasty (Ptca)
45 92921 Percutaneous Transluminal Coronary Angioplasty (Ptca)
45 92924 Percutaneous Transluminal Coronary Angioplasty (Ptca)
45 92925 Percutaneous Transluminal Coronary Angioplasty (Ptca)
45 92928 Percutaneous Transluminal Coronary Angioplasty (Ptca)
45 92929 Percutaneous Transluminal Coronary Angioplasty (Ptca)
45 92933 Percutaneous Transluminal Coronary Angioplasty (Ptca)
45 92934 Percutaneous Transluminal Coronary Angioplasty (Ptca)
45 92937 Percutaneous Transluminal Coronary Angioplasty (Ptca)
45 92938 Percutaneous Transluminal Coronary Angioplasty (Ptca)
45 92941 Percutaneous Transluminal Coronary Angioplasty (Ptca)
45 92943 Percutaneous Transluminal Coronary Angioplasty (Ptca)
45 92944 Percutaneous Transluminal Coronary Angioplasty (Ptca)
63 92950 Other Non-Or Therapeutic Cardiovascular Procedures
63 92953 Other Non-Or Therapeutic Cardiovascular Procedures
63 92960 Other Non-Or Therapeutic Cardiovascular Procedures
49 92961 Other Or Heart Procedures
50 92970 Extracorporeal Circulation Auxiliary To Open Heart Procedures
50 92971 Extracorporeal Circulation Auxiliary To Open Heart Procedures
45 92973 Percutaneous Transluminal Coronary Angioplasty (Ptca)
67 92974 Other Therapeutic Procedures, Hemic And Lymphatic System
46 92975 Coronary Thrombolysis
46 92977 Coronary Thrombolysis
193 92978 Diagnostic Ultrasound Of Heart (Echocardiogram)
193 92979 Diagnostic Ultrasound Of Heart (Echocardiogram)
43 92986 Heart Valve Procedures
43 92987 Heart Valve Procedures
43 92990 Heart Valve Procedures
49 92992 Other Or Heart Procedures
49 92993 Other Or Heart Procedures
54 92997 Other Vascular Catheterization, Not Heart
54 92998 Other Vascular Catheterization, Not Heart
202 93000 Electrocardiogram
202 93005 Electrocardiogram
202 93010 Electrocardiogram
201 93015 Cardiac Stress Tests
201 93016 Cardiac Stress Tests
201 93017 Cardiac Stress Tests
201 93018 Cardiac Stress Tests
62 93024 Other Diagnostic Cardiovascular Procedures
202 93025 Electrocardiogram
202 93040 Electrocardiogram
202 93041 Electrocardiogram
202 93042 Electrocardiogram
62 93050 Other Diagnostic Cardiovascular Procedures
203 93224 Electrographic Cardiac Monitoring
203 93225 Electrographic Cardiac Monitoring
203 93226 Electrographic Cardiac Monitoring
203 93227 Electrographic Cardiac Monitoring
203 93228 Electrographic Cardiac Monitoring
203 93229 Electrographic Cardiac Monitoring
62 93260 Other Diagnostic Cardiovascular Procedures
62 93261 Other Diagnostic Cardiovascular Procedures
62 93264 Other Diagnostic Cardiovascular Procedures
203 93268 Electrographic Cardiac Monitoring
203 93270 Electrographic Cardiac Monitoring
203 93271 Electrographic Cardiac Monitoring
203 93272 Electrographic Cardiac Monitoring
203 93278 Electrographic Cardiac Monitoring
203 93279 Electrographic Cardiac Monitoring
203 93280 Electrographic Cardiac Monitoring
203 93281 Electrographic Cardiac Monitoring
203 93282 Electrographic Cardiac Monitoring
203 93283 Electrographic Cardiac Monitoring
203 93284 Electrographic Cardiac Monitoring
203 93285 Electrographic Cardiac Monitoring
203 93286 Electrographic Cardiac Monitoring
203 93287 Electrographic Cardiac Monitoring
203 93288 Electrographic Cardiac Monitoring
203 93289 Electrographic Cardiac Monitoring
203 93290 Electrographic Cardiac Monitoring
203 93291 Electrographic Cardiac Monitoring
Blue Cross NC Proprietary and Confidential 114 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
203 93292 Electrographic Cardiac Monitoring
203 93293 Electrographic Cardiac Monitoring
203 93294 Electrographic Cardiac Monitoring
203 93295 Electrographic Cardiac Monitoring
203 93296 Electrographic Cardiac Monitoring
203 93297 Electrographic Cardiac Monitoring
203 93298 Electrographic Cardiac Monitoring
193 93303 Diagnostic Ultrasound Of Heart (Echocardiogram)
193 93304 Diagnostic Ultrasound Of Heart (Echocardiogram)
193 93306 Diagnostic Ultrasound Of Heart (Echocardiogram)
193 93307 Diagnostic Ultrasound Of Heart (Echocardiogram)
193 93308 Diagnostic Ultrasound Of Heart (Echocardiogram)
193 93312 Diagnostic Ultrasound Of Heart (Echocardiogram)
193 93313 Diagnostic Ultrasound Of Heart (Echocardiogram)
193 93314 Diagnostic Ultrasound Of Heart (Echocardiogram)
193 93315 Diagnostic Ultrasound Of Heart (Echocardiogram)
193 93316 Diagnostic Ultrasound Of Heart (Echocardiogram)
193 93317 Diagnostic Ultrasound Of Heart (Echocardiogram)
193 93318 Diagnostic Ultrasound Of Heart (Echocardiogram)
193 93320 Diagnostic Ultrasound Of Heart (Echocardiogram)
193 93321 Diagnostic Ultrasound Of Heart (Echocardiogram)
193 93325 Diagnostic Ultrasound Of Heart (Echocardiogram)
193 93350 Diagnostic Ultrasound Of Heart (Echocardiogram)
193 93351 Diagnostic Ultrasound Of Heart (Echocardiogram)
193 93352 Diagnostic Ultrasound Of Heart (Echocardiogram)
193 93355 Diagnostic Ultrasound Of Heart (Echocardiogram)
62 93356 Other Diagnostic Cardiovascular Procedures
47 93451 Diagnostic Cardiac Catheterization, Coronary Arteriography
47 93452 Diagnostic Cardiac Catheterization, Coronary Arteriography
47 93453 Diagnostic Cardiac Catheterization, Coronary Arteriography
47 93454 Diagnostic Cardiac Catheterization, Coronary Arteriography
47 93455 Diagnostic Cardiac Catheterization, Coronary Arteriography
47 93456 Diagnostic Cardiac Catheterization, Coronary Arteriography
47 93457 Diagnostic Cardiac Catheterization, Coronary Arteriography
47 93458 Diagnostic Cardiac Catheterization, Coronary Arteriography
47 93459 Diagnostic Cardiac Catheterization, Coronary Arteriography
47 93460 Diagnostic Cardiac Catheterization, Coronary Arteriography
47 93461 Diagnostic Cardiac Catheterization, Coronary Arteriography
47 93462 Diagnostic Cardiac Catheterization, Coronary Arteriography
47 93463 Diagnostic Cardiac Catheterization, Coronary Arteriography
47 93464 Diagnostic Cardiac Catheterization, Coronary Arteriography
204 93503 Swan-Ganz Catheterization For Monitoring
62 93505 Other Diagnostic Cardiovascular Procedures
47 93530 Diagnostic Cardiac Catheterization, Coronary Arteriography
47 93531 Diagnostic Cardiac Catheterization, Coronary Arteriography
47 93532 Diagnostic Cardiac Catheterization, Coronary Arteriography
47 93533 Diagnostic Cardiac Catheterization, Coronary Arteriography
47 93561 Diagnostic Cardiac Catheterization, Coronary Arteriography
47 93562 Diagnostic Cardiac Catheterization, Coronary Arteriography
47 93563 Diagnostic Cardiac Catheterization, Coronary Arteriography
47 93564 Diagnostic Cardiac Catheterization, Coronary Arteriography
47 93565 Diagnostic Cardiac Catheterization, Coronary Arteriography
47 93566 Diagnostic Cardiac Catheterization, Coronary Arteriography
47 93567 Diagnostic Cardiac Catheterization, Coronary Arteriography
47 93568 Diagnostic Cardiac Catheterization, Coronary Arteriography
47 93571 Diagnostic Cardiac Catheterization, Coronary Arteriography
47 93572 Diagnostic Cardiac Catheterization, Coronary Arteriography
49 93580 Other Or Heart Procedures
49 93581 Other Or Heart Procedures
49 93582 Other Or Heart Procedures
49 93583 Other Or Heart Procedures
43 93590 Heart Valve Procedures
43 93591 Heart Valve Procedures
43 93592 Heart Valve Procedures
62 93600 Other Diagnostic Cardiovascular Procedures
62 93602 Other Diagnostic Cardiovascular Procedures
62 93603 Other Diagnostic Cardiovascular Procedures
62 93609 Other Diagnostic Cardiovascular Procedures
62 93610 Other Diagnostic Cardiovascular Procedures
62 93612 Other Diagnostic Cardiovascular Procedures
62 93613 Other Diagnostic Cardiovascular Procedures
62 93615 Other Diagnostic Cardiovascular Procedures
62 93616 Other Diagnostic Cardiovascular Procedures
62 93618 Other Diagnostic Cardiovascular Procedures
Blue Cross NC Proprietary and Confidential 115 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
62 93619 Other Diagnostic Cardiovascular Procedures
62 93620 Other Diagnostic Cardiovascular Procedures
62 93621 Other Diagnostic Cardiovascular Procedures
62 93622 Other Diagnostic Cardiovascular Procedures
62 93623 Other Diagnostic Cardiovascular Procedures
62 93624 Other Diagnostic Cardiovascular Procedures
62 93631 Other Diagnostic Cardiovascular Procedures
62 93640 Other Diagnostic Cardiovascular Procedures
62 93641 Other Diagnostic Cardiovascular Procedures
62 93642 Other Diagnostic Cardiovascular Procedures
62 93644 Other Diagnostic Cardiovascular Procedures
225 93650 Conversion Of Cardiac Rhythm
225 93653 Conversion Of Cardiac Rhythm
225 93654 Conversion Of Cardiac Rhythm
225 93655 Conversion Of Cardiac Rhythm
225 93656 Conversion Of Cardiac Rhythm
225 93657 Conversion Of Cardiac Rhythm
203 93660 Electrographic Cardiac Monitoring
193 93662 Diagnostic Ultrasound Of Heart (Echocardiogram)
215 93668 Other Physical Therapy And Rehabilitation
62 93701 Other Diagnostic Cardiovascular Procedures
235 93702 Other Laboratory
203 93724 Electrographic Cardiac Monitoring
62 93740 Other Diagnostic Cardiovascular Procedures
203 93745 Electrographic Cardiac Monitoring
62 93750 Other Diagnostic Cardiovascular Procedures
62 93770 Other Diagnostic Cardiovascular Procedures
62 93784 Other Diagnostic Cardiovascular Procedures
62 93786 Other Diagnostic Cardiovascular Procedures
62 93788 Other Diagnostic Cardiovascular Procedures
62 93790 Other Diagnostic Cardiovascular Procedures
227 93792 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 93793 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
215 93797 Other Physical Therapy And Rehabilitation
215 93798 Other Physical Therapy And Rehabilitation
62 93799 Other Diagnostic Cardiovascular Procedures
192 93880 Diagnostic Ultrasound Of Head And Neck
192 93882 Diagnostic Ultrasound Of Head And Neck
192 93886 Diagnostic Ultrasound Of Head And Neck
192 93888 Diagnostic Ultrasound Of Head And Neck
192 93890 Diagnostic Ultrasound Of Head And Neck
192 93892 Diagnostic Ultrasound Of Head And Neck
192 93893 Diagnostic Ultrasound Of Head And Neck
192 93895 Diagnostic Ultrasound Of Head And Neck
62 93922 Other Diagnostic Cardiovascular Procedures
62 93923 Other Diagnostic Cardiovascular Procedures
62 93924 Other Diagnostic Cardiovascular Procedures
197 93925 Other Diagnostic Ultrasound
197 93926 Other Diagnostic Ultrasound
197 93930 Other Diagnostic Ultrasound
197 93931 Other Diagnostic Ultrasound
197 93970 Other Diagnostic Ultrasound
197 93971 Other Diagnostic Ultrasound
196 93975 Diagnostic Ultrasound Of Abdomen Or Retroperitoneum
196 93976 Diagnostic Ultrasound Of Abdomen Or Retroperitoneum
197 93978 Other Diagnostic Ultrasound
197 93979 Other Diagnostic Ultrasound
197 93980 Other Diagnostic Ultrasound
197 93981 Other Diagnostic Ultrasound
226 93985 Other Diagnostic Radiology And Related Techniques
226 93986 Other Diagnostic Radiology And Related Techniques
197 93990 Other Diagnostic Ultrasound
62 93998 Other Diagnostic Cardiovascular Procedures
231 94002 Other Therapeutic Procedures
231 94003 Other Therapeutic Procedures
231 94004 Other Therapeutic Procedures
236 94005 Home Health Services
38 94010 Other Diagnostic Procedures On Lung And Bronchus
38 94011 Other Diagnostic Procedures On Lung And Bronchus
38 94012 Other Diagnostic Procedures On Lung And Bronchus
38 94013 Other Diagnostic Procedures On Lung And Bronchus
38 94014 Other Diagnostic Procedures On Lung And Bronchus
38 94015 Other Diagnostic Procedures On Lung And Bronchus
38 94016 Other Diagnostic Procedures On Lung And Bronchus
Blue Cross NC Proprietary and Confidential 116 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
38 94060 Other Diagnostic Procedures On Lung And Bronchus
38 94070 Other Diagnostic Procedures On Lung And Bronchus
38 94150 Other Diagnostic Procedures On Lung And Bronchus
38 94200 Other Diagnostic Procedures On Lung And Bronchus
38 94250 Other Diagnostic Procedures On Lung And Bronchus
38 94375 Other Diagnostic Procedures On Lung And Bronchus
38 94400 Other Diagnostic Procedures On Lung And Bronchus
38 94450 Other Diagnostic Procedures On Lung And Bronchus
38 94452 Other Diagnostic Procedures On Lung And Bronchus
38 94453 Other Diagnostic Procedures On Lung And Bronchus
231 94610 Other Therapeutic Procedures
38 94617 Other Diagnostic Procedures On Lung And Bronchus
38 94618 Other Diagnostic Procedures On Lung And Bronchus
38 94621 Other Diagnostic Procedures On Lung And Bronchus
217 94640 Other Respiratory Therapy
217 94642 Other Respiratory Therapy
217 94644 Other Respiratory Therapy
217 94645 Other Respiratory Therapy
216 94660 Respiratory Intubation And Mechanical Ventilation
216 94662 Respiratory Intubation And Mechanical Ventilation
233 94664 Laboratory - Chemistry And Hematology
217 94667 Other Respiratory Therapy
217 94668 Other Respiratory Therapy
217 94669 Other Respiratory Therapy
233 94680 Laboratory - Chemistry And Hematology
233 94681 Laboratory - Chemistry And Hematology
233 94690 Laboratory - Chemistry And Hematology
38 94726 Other Diagnostic Procedures On Lung And Bronchus
38 94727 Other Diagnostic Procedures On Lung And Bronchus
38 94728 Other Diagnostic Procedures On Lung And Bronchus
38 94729 Other Diagnostic Procedures On Lung And Bronchus
233 94750 Laboratory - Chemistry And Hematology
233 94760 Laboratory - Chemistry And Hematology
233 94761 Laboratory - Chemistry And Hematology
233 94762 Laboratory - Chemistry And Hematology
233 94770 Laboratory - Chemistry And Hematology
226 94772 Other Diagnostic Radiology And Related Techniques
236 94774 Home Health Services
236 94775 Home Health Services
236 94776 Home Health Services
236 94777 Home Health Services
227 94780 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 94781 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
41 94799 Other Non-Or Therapeutic Procedures On Respiratory System
173 95004 Other Diagnostic Procedures On Skin And Subcutaneous Tissue
40 95012 Other Diagnostic Procedures Of Respiratory Tract And Mediastinum
173 95017 Other Diagnostic Procedures On Skin And Subcutaneous Tissue
173 95018 Other Diagnostic Procedures On Skin And Subcutaneous Tissue
173 95024 Other Diagnostic Procedures On Skin And Subcutaneous Tissue
173 95027 Other Diagnostic Procedures On Skin And Subcutaneous Tissue
173 95028 Other Diagnostic Procedures On Skin And Subcutaneous Tissue
173 95044 Other Diagnostic Procedures On Skin And Subcutaneous Tissue
173 95052 Other Diagnostic Procedures On Skin And Subcutaneous Tissue
173 95056 Other Diagnostic Procedures On Skin And Subcutaneous Tissue
173 95060 Other Diagnostic Procedures On Skin And Subcutaneous Tissue
173 95065 Other Diagnostic Procedures On Skin And Subcutaneous Tissue
173 95070 Other Diagnostic Procedures On Skin And Subcutaneous Tissue
173 95071 Other Diagnostic Procedures On Skin And Subcutaneous Tissue
173 95076 Other Diagnostic Procedures On Skin And Subcutaneous Tissue
173 95079 Other Diagnostic Procedures On Skin And Subcutaneous Tissue
M1B 95115 Office Visits-Established
M1B 95117 Office Visits-Established
M1B 95120 Office Visits-Established
M1B 95125 Office Visits-Established
M1B 95130 Office Visits-Established
M1B 95131 Office Visits-Established
M1B 95132 Office Visits-Established
M1B 95133 Office Visits-Established
M1B 95134 Office Visits-Established
M1B 95144 Office Visits-Established
M1B 95145 Office Visits-Established
M1B 95146 Office Visits-Established
M1B 95147 Office Visits-Established
M1B 95148 Office Visits-Established
Blue Cross NC Proprietary and Confidential 117 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
M1B 95149 Office Visits-Established
M1B 95165 Office Visits-Established
237 95170 Ancillary Services
231 95180 Other Therapeutic Procedures
231 95199 Other Therapeutic Procedures
11 95249 Diagnostic Endocrine Procedures
11 95250 Diagnostic Endocrine Procedures
11 95251 Diagnostic Endocrine Procedures
199 95700 Electroencephalogram (EEG)
199 95705 Electroencephalogram (EEG)
199 95706 Electroencephalogram (EEG)
199 95707 Electroencephalogram (EEG)
199 95708 Electroencephalogram (EEG)
199 95709 Electroencephalogram (EEG)
199 95710 Electroencephalogram (EEG)
199 95711 Electroencephalogram (EEG)
199 95712 Electroencephalogram (EEG)
199 95713 Electroencephalogram (EEG)
199 95714 Electroencephalogram (EEG)
199 95715 Electroencephalogram (EEG)
199 95716 Electroencephalogram (EEG)
199 95717 Electroencephalogram (EEG)
199 95718 Electroencephalogram (EEG)
199 95719 Electroencephalogram (EEG)
199 95720 Electroencephalogram (EEG)
199 95721 Electroencephalogram (EEG)
199 95722 Electroencephalogram (EEG)
199 95723 Electroencephalogram (EEG)
199 95724 Electroencephalogram (EEG)
199 95725 Electroencephalogram (EEG)
199 95726 Electroencephalogram (EEG)
227 95782 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 95783 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 95800 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 95801 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 95803 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 95805 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 95806 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 95807 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 95808 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 95810 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 95811 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
199 95812 Electroencephalogram (EEG)
199 95813 Electroencephalogram (EEG)
199 95816 Electroencephalogram (EEG)
199 95819 Electroencephalogram (EEG)
199 95822 Electroencephalogram (EEG)
199 95824 Electroencephalogram (EEG)
199 95829 Electroencephalogram (EEG)
199 95830 Electroencephalogram (EEG)
199 95836 Electroencephalogram (EEG)
212 95851 Diagnostic Physical Therapy
212 95852 Diagnostic Physical Therapy
7 95857 Other Diagnostic Nervous System Procedures
7 95860 Other Diagnostic Nervous System Procedures
7 95861 Other Diagnostic Nervous System Procedures
7 95863 Other Diagnostic Nervous System Procedures
7 95864 Other Diagnostic Nervous System Procedures
7 95865 Other Diagnostic Nervous System Procedures
7 95866 Other Diagnostic Nervous System Procedures
7 95867 Other Diagnostic Nervous System Procedures
7 95868 Other Diagnostic Nervous System Procedures
7 95869 Other Diagnostic Nervous System Procedures
7 95870 Other Diagnostic Nervous System Procedures
7 95872 Other Diagnostic Nervous System Procedures
8 95873 Other Non-Or Or Closed Therapeutic Nervous System Procedures
7 95874 Other Diagnostic Nervous System Procedures
7 95875 Other Diagnostic Nervous System Procedures
7 95885 Other Diagnostic Nervous System Procedures
7 95886 Other Diagnostic Nervous System Procedures
7 95887 Other Diagnostic Nervous System Procedures
7 95905 Other Diagnostic Nervous System Procedures
7 95907 Other Diagnostic Nervous System Procedures
7 95908 Other Diagnostic Nervous System Procedures
Blue Cross NC Proprietary and Confidential 118 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
7 95909 Other Diagnostic Nervous System Procedures
7 95910 Other Diagnostic Nervous System Procedures
7 95911 Other Diagnostic Nervous System Procedures
7 95912 Other Diagnostic Nervous System Procedures
7 95913 Other Diagnostic Nervous System Procedures
7 95921 Other Diagnostic Nervous System Procedures
7 95922 Other Diagnostic Nervous System Procedures
7 95923 Other Diagnostic Nervous System Procedures
7 95924 Other Diagnostic Nervous System Procedures
7 95925 Other Diagnostic Nervous System Procedures
7 95926 Other Diagnostic Nervous System Procedures
7 95927 Other Diagnostic Nervous System Procedures
7 95928 Other Diagnostic Nervous System Procedures
7 95929 Other Diagnostic Nervous System Procedures
7 95930 Other Diagnostic Nervous System Procedures
7 95933 Other Diagnostic Nervous System Procedures
7 95937 Other Diagnostic Nervous System Procedures
7 95938 Other Diagnostic Nervous System Procedures
7 95939 Other Diagnostic Nervous System Procedures
7 95940 Other Diagnostic Nervous System Procedures
7 95941 Other Diagnostic Nervous System Procedures
7 95943 Other Diagnostic Nervous System Procedures
199 95954 Electroencephalogram (EEG)
199 95955 Electroencephalogram (EEG)
199 95957 Electroencephalogram (EEG)
199 95958 Electroencephalogram (EEG)
199 95961 Electroencephalogram (EEG)
199 95962 Electroencephalogram (EEG)
7 95965 Other Diagnostic Nervous System Procedures
7 95966 Other Diagnostic Nervous System Procedures
7 95967 Other Diagnostic Nervous System Procedures
7 95970 Other Diagnostic Nervous System Procedures
7 95971 Other Diagnostic Nervous System Procedures
7 95972 Other Diagnostic Nervous System Procedures
7 95976 Other Diagnostic Nervous System Procedures
7 95977 Other Diagnostic Nervous System Procedures
7 95980 Other Diagnostic Nervous System Procedures
7 95981 Other Diagnostic Nervous System Procedures
7 95982 Other Diagnostic Nervous System Procedures
7 95983 Other Diagnostic Nervous System Procedures
7 95984 Other Diagnostic Nervous System Procedures
8 95990 Other Non-Or Or Closed Therapeutic Nervous System Procedures
8 95991 Other Non-Or Or Closed Therapeutic Nervous System Procedures
8 95992 Other Non-Or Or Closed Therapeutic Nervous System Procedures
7 95999 Other Diagnostic Nervous System Procedures
7 96000 Other Diagnostic Nervous System Procedures
7 96001 Other Diagnostic Nervous System Procedures
7 96002 Other Diagnostic Nervous System Procedures
7 96003 Other Diagnostic Nervous System Procedures
227 96004 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
7 96020 Other Diagnostic Nervous System Procedures
227 96040 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
218 96105 Psychological And Psychiatric Evaluation And Therapy
218 96110 Psychological And Psychiatric Evaluation And Therapy
227 96112 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 96113 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
218 96116 Psychological And Psychiatric Evaluation And Therapy
227 96121 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
218 96125 Psychological And Psychiatric Evaluation And Therapy
218 96127 Psychological And Psychiatric Evaluation And Therapy
218 96130 Psychological And Psychiatric Evaluation And Therapy
218 96131 Psychological And Psychiatric Evaluation And Therapy
218 96132 Psychological And Psychiatric Evaluation And Therapy
218 96133 Psychological And Psychiatric Evaluation And Therapy
218 96136 Psychological And Psychiatric Evaluation And Therapy
218 96137 Psychological And Psychiatric Evaluation And Therapy
218 96138 Psychological And Psychiatric Evaluation And Therapy
218 96139 Psychological And Psychiatric Evaluation And Therapy
218 96146 Psychological And Psychiatric Evaluation And Therapy
227 96156 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
231 96158 Other Therapeutic Procedures
231 96159 Other Therapeutic Procedures
227 96160 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 96161 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
Blue Cross NC Proprietary and Confidential 119 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
231 96164 Other Therapeutic Procedures
231 96165 Other Therapeutic Procedures
231 96167 Other Therapeutic Procedures
231 96168 Other Therapeutic Procedures
231 96170 Other Therapeutic Procedures
231 96171 Other Therapeutic Procedures
231 96360 Other Therapeutic Procedures
231 96361 Other Therapeutic Procedures
231 96365 Other Therapeutic Procedures
231 96366 Other Therapeutic Procedures
231 96367 Other Therapeutic Procedures
231 96368 Other Therapeutic Procedures
231 96369 Other Therapeutic Procedures
231 96370 Other Therapeutic Procedures
231 96371 Other Therapeutic Procedures
231 96372 Other Therapeutic Procedures
231 96373 Other Therapeutic Procedures
231 96374 Other Therapeutic Procedures
231 96375 Other Therapeutic Procedures
231 96376 Other Therapeutic Procedures
231 96377 Other Therapeutic Procedures
231 96379 Other Therapeutic Procedures
224 96401 Cancer Chemotherapy
224 96402 Cancer Chemotherapy
224 96405 Cancer Chemotherapy
224 96406 Cancer Chemotherapy
224 96409 Cancer Chemotherapy
224 96411 Cancer Chemotherapy
224 96413 Cancer Chemotherapy
224 96415 Cancer Chemotherapy
224 96416 Cancer Chemotherapy
224 96417 Cancer Chemotherapy
224 96420 Cancer Chemotherapy
224 96422 Cancer Chemotherapy
224 96423 Cancer Chemotherapy
224 96425 Cancer Chemotherapy
224 96440 Cancer Chemotherapy
224 96446 Cancer Chemotherapy
224 96450 Cancer Chemotherapy
224 96521 Cancer Chemotherapy
224 96522 Cancer Chemotherapy
224 96523 Cancer Chemotherapy
224 96542 Cancer Chemotherapy
224 96549 Cancer Chemotherapy
174 96567 Other Non-Or Therapeutic Procedures On Skin And Breast
174 96570 Other Non-Or Therapeutic Procedures On Skin And Breast
174 96571 Other Non-Or Therapeutic Procedures On Skin And Breast
174 96573 Other Non-Or Therapeutic Procedures On Skin And Breast
174 96574 Other Non-Or Therapeutic Procedures On Skin And Breast
174 96900 Other Non-Or Therapeutic Procedures On Skin And Breast
206 96902 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
174 96904 Other Non-Or Therapeutic Procedures On Skin And Breast
174 96910 Other Non-Or Therapeutic Procedures On Skin And Breast
174 96912 Other Non-Or Therapeutic Procedures On Skin And Breast
174 96913 Other Non-Or Therapeutic Procedures On Skin And Breast
174 96920 Other Non-Or Therapeutic Procedures On Skin And Breast
174 96921 Other Non-Or Therapeutic Procedures On Skin And Breast
174 96922 Other Non-Or Therapeutic Procedures On Skin And Breast
173 96931 Other Diagnostic Procedures On Skin And Subcutaneous Tissue
173 96932 Other Diagnostic Procedures On Skin And Subcutaneous Tissue
173 96933 Other Diagnostic Procedures On Skin And Subcutaneous Tissue
173 96934 Other Diagnostic Procedures On Skin And Subcutaneous Tissue
173 96935 Other Diagnostic Procedures On Skin And Subcutaneous Tissue
173 96936 Other Diagnostic Procedures On Skin And Subcutaneous Tissue
174 96999 Other Non-Or Therapeutic Procedures On Skin And Breast
213 97010 Physical Therapy Exercises, Manipulation, And Other Procedures
214 97012 Traction, Splints, And Other Wound Care
213 97014 Physical Therapy Exercises, Manipulation, And Other Procedures
213 97016 Physical Therapy Exercises, Manipulation, And Other Procedures
213 97018 Physical Therapy Exercises, Manipulation, And Other Procedures
213 97022 Physical Therapy Exercises, Manipulation, And Other Procedures
213 97024 Physical Therapy Exercises, Manipulation, And Other Procedures
213 97026 Physical Therapy Exercises, Manipulation, And Other Procedures
213 97028 Physical Therapy Exercises, Manipulation, And Other Procedures
Blue Cross NC Proprietary and Confidential 120 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
213 97032 Physical Therapy Exercises, Manipulation, And Other Procedures
213 97033 Physical Therapy Exercises, Manipulation, And Other Procedures
213 97034 Physical Therapy Exercises, Manipulation, And Other Procedures
213 97035 Physical Therapy Exercises, Manipulation, And Other Procedures
214 97036 Traction, Splints, And Other Wound Care
213 97039 Physical Therapy Exercises, Manipulation, And Other Procedures
213 97110 Physical Therapy Exercises, Manipulation, And Other Procedures
213 97112 Physical Therapy Exercises, Manipulation, And Other Procedures
213 97113 Physical Therapy Exercises, Manipulation, And Other Procedures
213 97116 Physical Therapy Exercises, Manipulation, And Other Procedures
213 97124 Physical Therapy Exercises, Manipulation, And Other Procedures
215 97129 Other Physical Therapy And Rehabilitation
215 97130 Other Physical Therapy And Rehabilitation
213 97139 Physical Therapy Exercises, Manipulation, And Other Procedures
213 97140 Physical Therapy Exercises, Manipulation, And Other Procedures
213 97150 Physical Therapy Exercises, Manipulation, And Other Procedures
218 97151 Psychological And Psychiatric Evaluation And Therapy
218 97152 Psychological And Psychiatric Evaluation And Therapy
218 97153 Psychological And Psychiatric Evaluation And Therapy
218 97154 Psychological And Psychiatric Evaluation And Therapy
218 97155 Psychological And Psychiatric Evaluation And Therapy
218 97156 Psychological And Psychiatric Evaluation And Therapy
218 97157 Psychological And Psychiatric Evaluation And Therapy
218 97158 Psychological And Psychiatric Evaluation And Therapy
213 97161 Physical Therapy Exercises, Manipulation, And Other Procedures
213 97162 Physical Therapy Exercises, Manipulation, And Other Procedures
213 97163 Physical Therapy Exercises, Manipulation, And Other Procedures
213 97164 Physical Therapy Exercises, Manipulation, And Other Procedures
213 97165 Physical Therapy Exercises, Manipulation, And Other Procedures
213 97166 Physical Therapy Exercises, Manipulation, And Other Procedures
213 97167 Physical Therapy Exercises, Manipulation, And Other Procedures
213 97168 Physical Therapy Exercises, Manipulation, And Other Procedures
213 97169 Physical Therapy Exercises, Manipulation, And Other Procedures
213 97170 Physical Therapy Exercises, Manipulation, And Other Procedures
213 97171 Physical Therapy Exercises, Manipulation, And Other Procedures
213 97172 Physical Therapy Exercises, Manipulation, And Other Procedures
213 97530 Physical Therapy Exercises, Manipulation, And Other Procedures
213 97533 Physical Therapy Exercises, Manipulation, And Other Procedures
213 97535 Physical Therapy Exercises, Manipulation, And Other Procedures
213 97537 Physical Therapy Exercises, Manipulation, And Other Procedures
213 97542 Physical Therapy Exercises, Manipulation, And Other Procedures
213 97545 Physical Therapy Exercises, Manipulation, And Other Procedures
213 97546 Physical Therapy Exercises, Manipulation, And Other Procedures
214 97597 Traction, Splints, And Other Wound Care
214 97598 Traction, Splints, And Other Wound Care
214 97602 Traction, Splints, And Other Wound Care
214 97605 Traction, Splints, And Other Wound Care
214 97606 Traction, Splints, And Other Wound Care
214 97607 Traction, Splints, And Other Wound Care
214 97608 Traction, Splints, And Other Wound Care
231 97610 Other Therapeutic Procedures
212 97750 Diagnostic Physical Therapy
213 97755 Physical Therapy Exercises, Manipulation, And Other Procedures
213 97760 Physical Therapy Exercises, Manipulation, And Other Procedures
213 97761 Physical Therapy Exercises, Manipulation, And Other Procedures
213 97763 Physical Therapy Exercises, Manipulation, And Other Procedures
213 97799 Physical Therapy Exercises, Manipulation, And Other Procedures
237 97802 Ancillary Services
237 97803 Ancillary Services
237 97804 Ancillary Services
213 97810 Physical Therapy Exercises, Manipulation, And Other Procedures
213 97811 Physical Therapy Exercises, Manipulation, And Other Procedures
213 97813 Physical Therapy Exercises, Manipulation, And Other Procedures
213 97814 Physical Therapy Exercises, Manipulation, And Other Procedures
213 98925 Physical Therapy Exercises, Manipulation, And Other Procedures
213 98926 Physical Therapy Exercises, Manipulation, And Other Procedures
213 98927 Physical Therapy Exercises, Manipulation, And Other Procedures
213 98928 Physical Therapy Exercises, Manipulation, And Other Procedures
213 98929 Physical Therapy Exercises, Manipulation, And Other Procedures
O1B 98940 Chiropratic
O1B 98941 Chiropratic
O1B 98942 Chiropratic
O1B 98943 Chiropratic
237 98960 Ancillary Services
Blue Cross NC Proprietary and Confidential 121 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
237 98961 Ancillary Services
237 98962 Ancillary Services
237 98966 Ancillary Services
237 98967 Ancillary Services
237 98968 Ancillary Services
M1B 98970 Office Visits - Established
M1B 98971 Office Visits - Established
M1B 98972 Office Visits - Established
237 99000 Ancillary Services
237 99001 Ancillary Services
237 99002 Ancillary Services
231 99024 Other Therapeutic Procedures
M3 99026 Emergency Room Visit
M3 99027 Emergency Room Visit
227 99050 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
231 99051 Other Therapeutic Procedures
231 99053 Other Therapeutic Procedures
227 99056 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
M1B 99058 Office Visits - Established
231 99060 Other Therapeutic Procedures
237 99070 Ancillary Services
237 99071 Ancillary Services
237 99075 Ancillary Services
237 99078 Ancillary Services
237 99080 Ancillary Services
237 99082 Ancillary Services
227 99091 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
232 99151 Anesthesia
232 99152 Anesthesia
232 99153 Anesthesia
232 99155 Anesthesia
232 99156 Anesthesia
232 99157 Anesthesia
227 99170 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
220 99172 Ophthalmologic And Otologic Diagnosis And Treatment
220 99173 Ophthalmologic And Otologic Diagnosis And Treatment
220 99174 Ophthalmologic And Otologic Diagnosis And Treatment
98 99175 Other Non-Or Gastrointestinal Therapeutic Procedures
220 99177 Ophthalmologic And Otologic Diagnosis And Treatment
231 99183 Other Therapeutic Procedures
231 99184 Other Therapeutic Procedures
32 99188 Other Non-Or Therapeutic Procedures On Nose, Mouth And Pharynx
237 99190 Ancillary Services
237 99191 Ancillary Services
237 99192 Ancillary Services
231 99195 Other Therapeutic Procedures
237 99199 Ancillary Services
M1A 99201 Office Visits - New
M1A 99202 Office Visits - New
M1A 99203 Office Visits - New
M1A 99204 Office Visits - New
M1A 99205 Office Visits - New
M1B 99211 Office Visits - Established
M1B 99212 Office Visits - Established
M1B 99213 Office Visits - Established
M1B 99214 Office Visits - Established
M1B 99215 Office Visits - Established
M2B 99217 Hospital Visit - Subsequent
M2A 99218 Hospital Visit - Initial
M2A 99219 Hospital Visit - Initial
M2A 99220 Hospital Visit - Initial
M2A 99221 Hospital Visit - Initial
M2A 99222 Hospital Visit - Initial
M2A 99223 Hospital Visit - Initial
M2B 99224 Hospital Visit - Subsequent
M2B 99225 Hospital Visit - Subsequent
M2B 99226 Hospital Visit - Subsequent
M2B 99231 Hospital Visit - Subsequent
M2B 99232 Hospital Visit - Subsequent
M2B 99233 Hospital Visit - Subsequent
M2B 99234 Hospital Visit - Subsequent
M2B 99235 Hospital Visit - Subsequent
M2B 99236 Hospital Visit - Subsequent
M2B 99238 Hospital Visit - Subsequent
Blue Cross NC Proprietary and Confidential 122 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
M2B 99239 Hospital Visit - Subsequent
M6 99241 OP Consultations
M6 99242 OP Consultations
M6 99243 OP Consultations
M6 99244 OP Consultations
M6 99245 OP Consultations
M6 99251 IP Consultations
M6 99252 IP Consultations
M6 99253 IP Consultations
M6 99254 IP Consultations
M6 99255 IP Consultations
M3 99281 Emergency Room Visit
M3 99282 Emergency Room Visit
M3 99283 Emergency Room Visit
M3 99284 Emergency Room Visit
M3 99285 Emergency Room Visit
231 99288 Other Therapeutic Procedures
M2C 99291 Hospital Visit - Critical Care
M2C 99292 Hospital Visit - Critical Care
M4B 99304 Nursing Home Visit
M4B 99305 Nursing Home Visit
M4B 99306 Nursing Home Visit
M4B 99307 Nursing Home Visit
M4B 99308 Nursing Home Visit
M4B 99309 Nursing Home Visit
M4B 99310 Nursing Home Visit
M4B 99315 Nursing Home Visit
M4B 99316 Nursing Home Visit
M4B 99318 Nursing Home Visit
M4B 99324 Nursing Home Visit
M4B 99325 Nursing Home Visit
M4B 99326 Nursing Home Visit
M4B 99327 Nursing Home Visit
M4B 99328 Nursing Home Visit
M4B 99334 Nursing Home Visit
M4B 99335 Nursing Home Visit
M4B 99336 Nursing Home Visit
M4B 99337 Nursing Home Visit
227 99339 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 99340 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 99341 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 99342 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 99343 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 99344 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 99345 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 99347 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 99348 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 99349 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 99350 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
M1B 99354 Office Visits - Established
M1B 99355 Office Visits - Established
M2B 99356 Hospital Visit - Subsequent
M2B 99357 Hospital Visit - Subsequent
227 99358 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 99359 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 99360 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
M1B 99366 Office Visits - Established
M1B 99367 Office Visits - Established
227 99368 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 99374 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 99375 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 99377 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 99378 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 99379 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 99380 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
M1A 99381 Office Visits - New
M1A 99382 Office Visits - New
M1A 99383 Office Visits - New
M1A 99384 Office Visits - New
M1A 99385 Office Visits - New
M1A 99386 Office Visits - New
M1A 99387 Office Visits - New
M1B 99391 Office Visits - Established
M1B 99392 Office Visits - Established
Blue Cross NC Proprietary and Confidential 123 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
M1B 99393 Office Visits - Established
M1B 99394 Office Visits - Established
M1B 99395 Office Visits - Established
M1B 99396 Office Visits - Established
M1B 99397 Office Visits - Established
M1B 99401 Office Visits - Established
M1B 99402 Office Visits - Established
M1B 99403 Office Visits - Established
M1B 99404 Office Visits - Established
227 99406 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 99407 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 99408 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 99409 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
M1B 99411 Office Visits - Established
M1B 99412 Office Visits - Established
237 99415 Ancillary Services
237 99416 Ancillary Services
M1B 99421 Office Visits - Established
M1B 99422 Office Visits - Established
M1B 99423 Office Visits - Established
M1B 99429 Office Visits - Established
227 99441 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 99442 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 99443 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 99446 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 99447 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 99448 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 99449 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 99450 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
M6 99451 OP Consultations
M6 99452 OP Consultations
231 99453 Other Therapeutic Procedures
231 99454 Other Therapeutic Procedures
227 99455 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 99456 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
231 99457 Other Therapeutic Procedures
226 99458 Other Diagnostic Radiology And Related Techniques
M6 99460 IP Consultations
M6 99461 IP Consultations
M6 99462 IP Consultations
M6 99463 IP Consultations
231 99464 Other Therapeutic Procedures
231 99465 Other Therapeutic Procedures
231 99466 Other Therapeutic Procedures
231 99467 Other Therapeutic Procedures
M2C 99468 Hospital Visit - Critical Care
M2C 99469 Hospital Visit - Critical Care
M2C 99471 Hospital Visit - Critical Care
M2C 99472 Hospital Visit - Critical Care
62 99473 Other Diagnostic Cardiovascular Procedures
62 99474 Other Diagnostic Cardiovascular Procedures
M2C 99475 Hospital Visit - Critical Care
M2C 99476 Hospital Visit - Critical Care
M6 99477 IP Consultations
M6 99478 IP Consultations
M6 99479 IP Consultations
M6 99480 IP Consultations
227 99483 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 99484 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
231 99485 Other Therapeutic Procedures
231 99486 Other Therapeutic Procedures
227 99487 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 99489 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 99490 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 99491 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 99492 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 99493 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 99494 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 99495 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 99496 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 99497 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 99498 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 99499 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
236 99500 Home Health Services
Blue Cross NC Proprietary and Confidential 124 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
236 99501 Home Health Services
236 99502 Home Health Services
236 99503 Home Health Services
236 99504 Home Health Services
236 99505 Home Health Services
236 99506 Home Health Services
236 99507 Home Health Services
236 99509 Home Health Services
236 99510 Home Health Services
236 99511 Home Health Services
236 99512 Home Health Services
236 99600 Home Health Services
236 99601 Home Health Services
236 99602 Home Health Services
227 99605 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 99606 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 99607 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
235 0001M Other Laboratory
234 0001U Pathology
235 0002M Other Laboratory
234 0002U Pathology
235 0003M Other Laboratory
234 0003U Pathology
235 0004M Other Laboratory
234 0005U Pathology
234 0006M Pathology
234 0007M Pathology
235 0007U Other Laboratory
206 0008U Microscopic Examination (Bacterial Smear, Culture, Toxicology)
234 0009U Pathology
234 0010U Pathology
234 0011M Pathology
235 0011U Other Laboratory
234 0012M Pathology
234 0012U Pathology
234 0013M Pathology
234 0013U Pathology
234 0014M Pathology
234 0014U Pathology
234 0015U Pathology
234 0016U Pathology
234 0017U Pathology
234 0018U Pathology
234 0019U Pathology
234 0022U Pathology
234 0023U Pathology
49 0024T Other Or Heart Procedures
235 0024U Other Laboratory
235 0025U Other Laboratory
234 0026U Pathology
234 0027U Pathology
234 0028U Pathology
234 0029U Pathology
234 0030U Pathology
234 0031U Pathology
234 0032U Pathology
234 0033U Pathology
234 0034U Pathology
235 0035U Other Laboratory
234 0036U Pathology
234 0037U Pathology
235 0038U Other Laboratory
234 0039U Pathology
234 0040U Pathology
235 0041U Other Laboratory
180 0042T Other CT Scan
235 0042U Other Laboratory
235 0043U Other Laboratory
235 0044U Other Laboratory
234 0045U Pathology
234 0046U Pathology
234 0047U Pathology
234 0048U Pathology
234 0049U Pathology
Blue Cross NC Proprietary and Confidential 125 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
234 0050U Pathology
234 0051U Pathology
234 0052U Pathology
234 0053U Pathology
226 0054T Other Diagnostic Radiology And Related Techniques
234 0054U Pathology
226 0055T Other Diagnostic Radiology And Related Techniques
234 0055U Pathology
234 0056U Pathology
234 0057U Pathology
235 0058T Other Laboratory
234 0058U Pathology
234 0059U Pathology
234 0060U Pathology
235 0061U Other Laboratory
131 0071T Other Non-Or Therapeutic Procedures, Female Organs
131 0072T Other Non-Or Therapeutic Procedures, Female Organs
59 0075T Other Or Procedures On Vessels Of Head And Neck
59 0076T Other Or Procedures On Vessels Of Head And Neck
235 0080U Other Laboratory
235 0082U Other Laboratory
235 0083U Other Laboratory
235 0084U Other Laboratory
62 0085T Other Diagnostic Cardiovascular Procedures
235 0086U Other Laboratory
235 0087U Other Laboratory
235 0088U Other Laboratory
235 0089U Other Laboratory
235 0090U Other Laboratory
235 0091U Other Laboratory
235 0092U Other Laboratory
235 0093U Other Laboratory
235 0094U Other Laboratory
162 0095T Other Or Therapeutic Procedures On Joints
235 0095U Other Laboratory
235 0096U Other Laboratory
235 0097U Other Laboratory
154 0098T Arthroplasty Other Than Hip Or Knee
235 0098U Other Laboratory
235 0099U Other Laboratory
20 0100T Other Intraocular Therapeutic Procedures
235 0100U Other Laboratory
163 0101T Other Non-Or Therapeutic Procedures On Musculoskeletal System
235 0101U Other Laboratory
162 0102T Other Or Therapeutic Procedures On Joints
235 0102U Other Laboratory
235 0103U Other Laboratory
235 0105U Other Laboratory
7 0106T Other Diagnostic Nervous System Procedures
235 0106U Other Laboratory
7 0107T Other Diagnostic Nervous System Procedures
235 0107U Other Laboratory
7 0108T Other Diagnostic Nervous System Procedures
235 0108U Other Laboratory
7 0109T Other Diagnostic Nervous System Procedures
235 0109U Other Laboratory
7 0110T Other Diagnostic Nervous System Procedures
235 0110U Other Laboratory
233 0111T Laboratory - Chemistry And Hematology
235 0111U Other Laboratory
235 0112U Other Laboratory
235 0113U Other Laboratory
235 0114U Other Laboratory
235 0115U Other Laboratory
235 0116U Other Laboratory
235 0117U Other Laboratory
235 0118U Other Laboratory
235 0119U Other Laboratory
235 0120U Other Laboratory
235 0121U Other Laboratory
235 0122U Other Laboratory
235 0123U Other Laboratory
235 0124U Other Laboratory
235 0125U Other Laboratory
Blue Cross NC Proprietary and Confidential 126 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
192 0126T Diagnostic Ultrasound Of Head And Neck
235 0126U Other Laboratory
235 0127U Other Laboratory
235 0128U Other Laboratory
235 0129U Other Laboratory
235 0130U Other Laboratory
235 0131U Other Laboratory
235 0132U Other Laboratory
235 0133U Other Laboratory
235 0134U Other Laboratory
235 0135U Other Laboratory
235 0136U Other Laboratory
235 0137U Other Laboratory
235 0138U Other Laboratory
234 0139U Pathology
234 0140U Pathology
234 0141U Pathology
234 0142U Pathology
234 0143U Pathology
234 0144U Pathology
234 0145U Pathology
234 0146U Pathology
234 0147U Pathology
234 0148U Pathology
234 0149U Pathology
234 0150U Pathology
234 0151U Pathology
234 0152U Pathology
234 0153U Pathology
234 0154U Pathology
234 0155U Pathology
234 0156U Pathology
234 0157U Pathology
234 0158U Pathology
234 0159U Pathology
234 0160U Pathology
234 0161U Pathology
234 0162U Pathology
158 0163T Spinal Fusion
234 0163U Pathology
158 0164T Spinal Fusion
234 0164U Pathology
158 0165T Spinal Fusion
234 0165U Pathology
234 0166U Pathology
234 0167U Pathology
234 0168U Pathology
234 0169U Pathology
234 0170U Pathology
234 0171U Pathology
183 0174T Routine Chest X-Ray
183 0175T Routine Chest X-Ray
96 0184T Other Or Lower GI Therapeutic Procedures
14 0191T Glaucoma Procedures
220 0198T Ophthalmologic And Otologic Diagnosis And Treatment
148 0200T Other Fracture And Dislocation Procedure
148 0201T Other Fracture And Dislocation Procedure
3 0202T Laminectomy, Excision Intervertebral Disc
19 0207T Ophthalmologic And Otologic Diagnosis And Treatment
220 0208T Ophthalmologic And Otologic Diagnosis And Treatment
220 0209T Ophthalmologic And Otologic Diagnosis And Treatment
220 0210T Ophthalmologic And Otologic Diagnosis And Treatment
220 0211T Ophthalmologic And Otologic Diagnosis And Treatment
220 0212T Ophthalmologic And Otologic Diagnosis And Treatment
231 0213T Other Therapeutic Procedures
231 0214T Other Therapeutic Procedures
231 0215T Other Therapeutic Procedures
231 0216T Other Therapeutic Procedures
231 0217T Other Therapeutic Procedures
231 0218T Other Therapeutic Procedures
164 0219T Other Or Therapeutic Procedures On Musculoskeletal System
164 0220T Other Or Therapeutic Procedures On Musculoskeletal System
164 0221T Other Or Therapeutic Procedures On Musculoskeletal System
164 0222T Other Or Therapeutic Procedures On Musculoskeletal System
Blue Cross NC Proprietary and Confidential 127 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
231 0228T Other Therapeutic Procedures
231 0229T Other Therapeutic Procedures
231 0230T Other Therapeutic Procedures
231 0231T Other Therapeutic Procedures
231 0232T Other Therapeutic Procedures
61 0234T Other Or Procedures On Vessels Other Than Head And Neck
61 0235T Other Or Procedures On Vessels Other Than Head And Neck
61 0236T Other Or Procedures On Vessels Other Than Head And Neck
61 0237T Other Or Procedures On Vessels Other Than Head And Neck
61 0238T Other Or Procedures On Vessels Other Than Head And Neck
14 0253T Glaucoma Procedures
156 0263T Injections And Aspirations Of Muscles, Tendons, Bursa, Joints And Soft Tissue
156 0264T Injections And Aspirations Of Muscles, Tendons, Bursa, Joints And Soft Tissue
67 0265T Other Therapeutic Procedures, Hemic And Lymphatic System
59 0266T Other Or Procedures On Vessels Of Head And Neck
59 0267T Other Or Procedures On Vessels Of Head And Neck
59 0268T Other Or Procedures On Vessels Of Head And Neck
59 0269T Other Or Procedures On Vessels Of Head And Neck
59 0270T Other Or Procedures On Vessels Of Head And Neck
59 0271T Other Or Procedures On Vessels Of Head And Neck
62 0272T Other Diagnostic Cardiovascular Procedures
63 0273T Other Non-Or Therapeutic Cardiovascular Procedures
3 0274T Laminectomy, Excision Intervertebral Disc
3 0275T Laminectomy, Excision Intervertebral Disc
8 0278T Other Non-Or Or Closed Therapeutic Nervous System Procedures
13 0290T Eye Procedure - Corneal Transplant
203 0295T Electrographic Cardiac Monitoring
203 0296T Electrographic Cardiac Monitoring
203 0297T Electrographic Cardiac Monitoring
203 0298T Electrographic Cardiac Monitoring
15 0308T Lens And Cataract Procedures
244 0312T Gastric Bypass And Volume Reduction
244 0313T Gastric Bypass And Volume Reduction
244 0314T Gastric Bypass And Volume Reduction
244 0315T Gastric Bypass And Volume Reduction
244 0316T Gastric Bypass And Volume Reduction
244 0317T Gastric Bypass And Volume Reduction
18 0329T Diagnostic Procedures On Eye
18 0330T Diagnostic Procedures On Eye
209 0331T Radioisotope Scan And Function Studies
209 0332T Radioisotope Scan And Function Studies
7 0333T Other Diagnostic Nervous System Procedures
162 0335T Other Or Therapeutic Procedures On Joints
9 0338T Other Or Therapeutic Nervous System Procedures
9 0339T Other Or Therapeutic Nervous System Procedures
231 0342T Other Therapeutic Procedures
43 0345T Heart Valve Procedures
226 0347T Other Diagnostic Radiology And Related Techniques
226 0348T Other Diagnostic Radiology And Related Techniques
226 0349T Other Diagnostic Radiology And Related Techniques
226 0350T Other Diagnostic Radiology And Related Techniques
180 0351T Other CT Scan
180 0352T Other CT Scan
180 0353T Other CT Scan
180 0354T Other CT Scan
97 0355T Other Gastrointestinal Diagnostic Procedures
21 0356T Other Extraocular Muscle And Orbit Therapeutic Procedures
227 0358T Other Diagnostic Procedures (Interview, Evaluation, Consultation)
218 0362T Psychological And Psychiatric Evaluation And Therapy
218 0373T Psychological And Psychiatric Evaluation And Therapy
20 0376T Other Intraocular Therapeutic Procedures
220 0378T Ophthalmologic And Otologic Diagnosis And Treatment
220 0379T Ophthalmologic And Otologic Diagnosis And Treatment
7 0381T Other Diagnostic Nervous System Procedures
7 0382T Other Diagnostic Nervous System Procedures
7 0383T Other Diagnostic Nervous System Procedures
7 0384T Other Diagnostic Nervous System Procedures
7 0385T Other Diagnostic Nervous System Procedures
7 0386T Other Diagnostic Nervous System Procedures
211 0394T Therapeutic Radiology
211 0395T Therapeutic Radiology
152 0396T Arthroplasty Knee
82 0397T Endoscopic Retrograde Cannulation Of Pancreas (ERCP)
9 0398T Other Or Therapeutic Nervous System Procedures
Blue Cross NC Proprietary and Confidential 128 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
173 0400T Other Diagnostic Procedures On Skin And Subcutaneous Tissue
173 0401T Other Diagnostic Procedures On Skin And Subcutaneous Tissue
19 0402T Ophthalmologic And Otologic Diagnosis And Treatment
237 0403T Ancillary Services
131 0404T Other Non-Or Therapeutic Procedures, Female Organs
237 0405T Ancillary Services
48 0408T Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 0409T Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 0410T Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 0411T Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 0412T Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 0413T Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 0414T Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 0415T Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 0416T Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
203 0417T Electrographic Cardiac Monitoring
203 0418T Electrographic Cardiac Monitoring
175 0419T Other Or Therapeutic Procedures On Skin And Breast
175 0420T Other Or Therapeutic Procedures On Skin And Breast
113 0421T Transurethral Resection Of Prostate (TURP)
226 0422T Other Diagnostic Radiology And Related Techniques
233 0423T Laboratory - Chemistry And Hematology
9 0424T Other Or Therapeutic Nervous System Procedures
9 0425T Other Or Therapeutic Nervous System Procedures
9 0426T Other Or Therapeutic Nervous System Procedures
9 0427T Other Or Therapeutic Nervous System Procedures
9 0428T Other Or Therapeutic Nervous System Procedures
9 0429T Other Or Therapeutic Nervous System Procedures
9 0430T Other Or Therapeutic Nervous System Procedures
9 0431T Other Or Therapeutic Nervous System Procedures
9 0432T Other Or Therapeutic Nervous System Procedures
9 0433T Other Or Therapeutic Nervous System Procedures
7 0434T Other Diagnostic Nervous System Procedures
7 0435T Other Diagnostic Nervous System Procedures
7 0436T Other Diagnostic Nervous System Procedures
99 0437T Other Or Gastrointestinal Therapeutic Procedures
62 0439T Other Diagnostic Cardiovascular Procedures
8 0440T Other Non-Or Or Closed Therapeutic Nervous System Procedures
8 0441T Other Non-Or Or Closed Therapeutic Nervous System Procedures
8 0442T Other Non-Or Or Closed Therapeutic Nervous System Procedures
116 0443T Diagnostic Procedures, Male Genital
21 0444T Other Extraocular Muscle And Orbit Therapeutic Procedures
21 0445T Other Extraocular Muscle And Orbit Therapeutic Procedures
11 0446T Diagnostic Endocrine Procedures
11 0447T Diagnostic Endocrine Procedures
11 0448T Diagnostic Endocrine Procedures
21 0449T Other Extraocular Muscle And Orbit Therapeutic Procedures
21 0450T Other Extraocular Muscle And Orbit Therapeutic Procedures
49 0451T Other Or Heart Procedures
49 0452T Other Or Heart Procedures
49 0453T Other Or Heart Procedures
49 0454T Other Or Heart Procedures
49 0455T Other Or Heart Procedures
49 0456T Other Or Heart Procedures
49 0457T Other Or Heart Procedures
49 0458T Other Or Heart Procedures
49 0459T Other Or Heart Procedures
49 0460T Other Or Heart Procedures
49 0461T Other Or Heart Procedures
49 0462T Other Or Heart Procedures
49 0463T Other Or Heart Procedures
7 0464T Other Diagnostic Nervous System Procedures
20 0465T Other Intraocular Therapeutic Procedures
9 0466T Other Or Therapeutic Nervous System Procedures
9 0467T Other Or Therapeutic Nervous System Procedures
9 0468T Other Or Therapeutic Nervous System Procedures
7 0469T Other Diagnostic Nervous System Procedures
174 0470T Other Non-Or Therapeutic Procedures On Skin And Breast
173 0471T Other Diagnostic Procedures On Skin And Subcutaneous Tissue
20 0472T Other Intraocular Therapeutic Procedures
20 0473T Other Intraocular Therapeutic Procedures
20 0474T Other Intraocular Therapeutic Procedures
62 0475T Other Diagnostic Cardiovascular Procedures
62 0476T Other Diagnostic Cardiovascular Procedures
Blue Cross NC Proprietary and Confidential 129 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
62 0477T Other Diagnostic Cardiovascular Procedures
62 0478T Other Diagnostic Cardiovascular Procedures
170 0479T Excision Of Skin Lesion
170 0480T Excision Of Skin Lesion
164 0481T Other Or Therapeutic Procedures On Musculoskeletal System
43 0483T Heart Valve Procedures
43 0484T Heart Valve Procedures
25 0485T Diagnostic Procedures On Ear
25 0486T Diagnostic Procedures On Ear
130 0487T Other Diagnostic Procedures, Female Organs
237 0488T Ancillary Services
174 0489T Other Non-Or Therapeutic Procedures On Skin And Breast
174 0490T Other Non-Or Therapeutic Procedures On Skin And Breast
174 0491T Other Non-Or Therapeutic Procedures On Skin And Breast
174 0492T Other Non-Or Therapeutic Procedures On Skin And Breast
173 0493T Other Diagnostic Procedures On Skin And Subcutaneous Tissue
176 0494T Other Organ Transplantation
176 0495T Other Organ Transplantation
176 0496T Other Organ Transplantation
203 0497T Electrographic Cardiac Monitoring
203 0498T Electrographic Cardiac Monitoring
109 0499T Procedures On The Urethra
206 0500T Microscopic Examination (Bacterial Smear, Culture, Toxicology)
180 0501T Other CT Scan
180 0502T Other CT Scan
180 0503T Other CT Scan
180 0504T Other CT Scan
61 0505T Other Or Procedures On Vessels Other Than Head And Neck
220 0506T Ophthalmologic And Otologic Diagnosis And Treatment
220 0507T Ophthalmologic And Otologic Diagnosis And Treatment
159 0508T Other Diagnostic Procedures On Musculoskeletal System
18 0509T Diagnostic Procedures On Eye
161 0510T Other Or Therapeutic Procedures On Bone
161 0511T Other Or Therapeutic Procedures On Bone
230 0512T Extracorporeal Shock Wave, Other Than Urinary
230 0513T Extracorporeal Shock Wave, Other Than Urinary
15 0514T Lens And Cataract Procedures
48 0515T Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 0516T Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 0517T Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 0518T Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 0519T Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 0520T Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
63 0521T Other Non-Or Therapeutic Cardiovascular Procedures
63 0522T Other Non-Or Therapeutic Cardiovascular Procedures
63 0523T Other Non-Or Therapeutic Cardiovascular Procedures
61 0524T Other Or Procedures On Vessels Other Than Head And Neck
61 0525T Other Or Procedures On Vessels Other Than Head And Neck
48 0526T Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 0527T Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
63 0528T Other Non-Or Therapeutic Cardiovascular Procedures
63 0529T Other Non-Or Therapeutic Cardiovascular Procedures
48 0530T Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 0531T Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 0532T Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
7 0533T Other Diagnostic Nervous System Procedures
7 0534T Other Diagnostic Nervous System Procedures
7 0535T Other Diagnostic Nervous System Procedures
7 0536T Other Diagnostic Nervous System Procedures
231 0537T Other Therapeutic Procedures
231 0538T Other Therapeutic Procedures
231 0539T Other Therapeutic Procedures
231 0540T Other Therapeutic Procedures
198 0541T Magnetic Resonance Imaging
198 0542T Magnetic Resonance Imaging
43 0543T Heart Valve Procedures
43 0544T Heart Valve Procedures
43 0545T Heart Valve Procedures
165 0546T Breast Biopsy And Other Diagnostic Procedures On Breast
159 0547T Other Diagnostic Procedures On Musculoskeletal System
112 0548T Other Or Therapeutic Procedures Of Urinary Tract
112 0549T Other Or Therapeutic Procedures Of Urinary Tract
112 0550T Other Or Therapeutic Procedures Of Urinary Tract
112 0551T Other Or Therapeutic Procedures Of Urinary Tract
Blue Cross NC Proprietary and Confidential 130 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
213 0552T Physical Therapy Exercises, Manipulation, And Other Procedures
61 0553T Other Or Procedures On Vessels Other Than Head And Neck
159 0554T Other Diagnostic Procedures On Musculoskeletal System
159 0555T Other Diagnostic Procedures On Musculoskeletal System
159 0556T Other Diagnostic Procedures On Musculoskeletal System
159 0557T Other Diagnostic Procedures On Musculoskeletal System
159 0558T Other Diagnostic Procedures On Musculoskeletal System
231 0559T Other Therapeutic Procedures
231 0560T Other Therapeutic Procedures
231 0561T Other Therapeutic Procedures
231 0562T Other Therapeutic Procedures
19 0563T Opthalmologic and Otologic
234 0564T Pathology
162 0565T Other Or Therapeutic Procedures On Joints
162 0566T Other Or Therapeutic Procedures On Joints
123 0567T Other Operations On Fallopian Tubes
123 0568T Other Operations On Fallopian Tubes
43 0569T Heart Valve Procedures
43 0570T Heart Valve Procedures
48 0571T Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 0572T Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 0573T Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
48 0574T Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
63 0575T Other Non-Or Therapeutic Cardiovascular Procedures
63 0576T Other Non-Or Therapeutic Cardiovascular Procedures
63 0577T Other Non-Or Therapeutic Cardiovascular Procedures
63 0578T Other Non-Or Therapeutic Cardiovascular Procedures
63 0579T Other Non-Or Therapeutic Cardiovascular Procedures
48 0580T Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
175 0581T Other Or Therapeutic Procedures On Skin And Breast
118 0582T Other Or Therapeutic Procedures, Male Genital
22 0583T Tympanoplasty
12 0584T Other Therapeutic Endocrine Procedures
12 0585T Other Therapeutic Endocrine Procedures
12 0586T Other Therapeutic Endocrine Procedures
8 0587T Other Non-Or Or Closed Therapeutic Nervous System Procedures
8 0588T Other Non-Or Or Closed Therapeutic Nervous System Procedures
8 0589T Other Non-Or Or Closed Therapeutic Nervous System Procedures
8 0590T Other Non-Or Or Closed Therapeutic Nervous System Procedures
231 0591T Other Therapeutic Procedures
231 0592T Other Therapeutic Procedures
231 0593T Other Therapeutic Procedures
239 A0021 Transportation - Patient, Provider, Equipment
239 A0080 Transportation - Patient, Provider, Equipment
239 A0090 Transportation - Patient, Provider, Equipment
239 A0100 Transportation - Patient, Provider, Equipment
239 A0110 Transportation - Patient, Provider, Equipment
239 A0120 Transportation - Patient, Provider, Equipment
239 A0130 Transportation - Patient, Provider, Equipment
239 A0140 Transportation - Patient, Provider, Equipment
239 A0160 Transportation - Patient, Provider, Equipment
239 A0170 Transportation - Patient, Provider, Equipment
239 A0180 Transportation - Patient, Provider, Equipment
239 A0190 Transportation - Patient, Provider, Equipment
239 A0200 Transportation - Patient, Provider, Equipment
239 A0210 Transportation - Patient, Provider, Equipment
239 A0225 Transportation - Patient, Provider, Equipment
239 A0380 Transportation - Patient, Provider, Equipment
239 A0382 Transportation - Patient, Provider, Equipment
239 A0384 Transportation - Patient, Provider, Equipment
239 A0390 Transportation - Patient, Provider, Equipment
239 A0392 Transportation - Patient, Provider, Equipment
239 A0394 Transportation - Patient, Provider, Equipment
239 A0396 Transportation - Patient, Provider, Equipment
239 A0398 Transportation - Patient, Provider, Equipment
239 A0420 Transportation - Patient, Provider, Equipment
239 A0422 Transportation - Patient, Provider, Equipment
239 A0424 Transportation - Patient, Provider, Equipment
239 A0425 Transportation - Patient, Provider, Equipment
239 A0426 Transportation - Patient, Provider, Equipment
239 A0427 Transportation - Patient, Provider, Equipment
239 A0428 Transportation - Patient, Provider, Equipment
239 A0429 Transportation - Patient, Provider, Equipment
239 A0430 Transportation - Patient, Provider, Equipment
Blue Cross NC Proprietary and Confidential 131 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
239 A0431 Transportation - Patient, Provider, Equipment
239 A0432 Transportation - Patient, Provider, Equipment
239 A0433 Transportation - Patient, Provider, Equipment
239 A0434 Transportation - Patient, Provider, Equipment
239 A0435 Transportation - Patient, Provider, Equipment
239 A0436 Transportation - Patient, Provider, Equipment
239 A0888 Transportation - Patient, Provider, Equipment
239 A0998 Transportation - Patient, Provider, Equipment
239 A0999 Transportation - Patient, Provider, Equipment
243 A4206 DME and supplies
243 A4207 DME and supplies
243 A4208 DME and supplies
243 A4209 DME and supplies
243 A4210 DME and supplies
243 A4211 DME and supplies
243 A4212 DME and supplies
243 A4213 DME and supplies
243 A4215 DME and supplies
243 A4216 DME and supplies
243 A4217 DME and supplies
243 A4218 DME and supplies
243 A4220 DME and supplies
243 A4221 DME and supplies
243 A4222 DME and supplies
243 A4223 DME and supplies
243V A4224 DME and supplies-Vendor
243V A4225 DME and supplies-Vendor
243V A4226 DME and supplies-Vendor
243V A4230 DME and supplies-Vendor
243V A4231 DME and supplies-Vendor
243V A4232 DME and supplies-Vendor
243V A4233 DME and supplies-Vendor
243V A4234 DME and supplies-Vendor
243V A4235 DME and supplies-Vendor
243V A4236 DME and supplies-Vendor
243V A4244 DME and supplies-Vendor
243V A4245 DME and supplies-Vendor
243V A4246 DME and supplies-Vendor
243V A4247 DME and supplies-Vendor
243V A4248 DME and supplies-Vendor
243V A4250 DME and supplies-Vendor
243 A4252 DME and supplies
243 A4253 DME and supplies
243V A4255 DME and supplies-Vendor
243V A4256 DME and supplies-Vendor
243V A4257 DME and supplies-Vendor
243V A4258 DME and supplies-Vendor
243V A4259 DME and supplies-Vendor
243 A4261 DME and supplies
243 A4262 DME and supplies
243 A4263 DME and supplies
243V A4264 DME and supplies-Vendor
243V A4265 DME and supplies-Vendor
243 A4266 DME and supplies
243 A4267 DME and supplies
243 A4268 DME and supplies
243 A4269 DME and supplies
243 A4270 DME and supplies
243 A4280 DME and supplies
243V A4281 DME and supplies-Vendor
243V A4282 DME and supplies-Vendor
243V A4283 DME and supplies-Vendor
243V A4284 DME and supplies-Vendor
243V A4285 DME and supplies-Vendor
243V A4286 DME and supplies-Vendor
243 A4290 DME and supplies
243 A4300 DME and supplies
243 A4301 DME and supplies
243 A4305 DME and supplies
243 A4306 DME and supplies
243 A4310 DME and supplies
243 A4311 DME and supplies
243 A4312 DME and supplies
243 A4313 DME and supplies
Blue Cross NC Proprietary and Confidential 132 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
243 A4314 DME and supplies
243 A4315 DME and supplies
243 A4316 DME and supplies
243 A4320 DME and supplies
243 A4321 DME and supplies
243 A4322 DME and supplies
243 A4326 DME and supplies
243 A4327 DME and supplies
243 A4328 DME and supplies
243 A4330 DME and supplies
243 A4331 DME and supplies
243 A4332 DME and supplies
243 A4333 DME and supplies
243 A4334 DME and supplies
243 A4335 DME and supplies
243 A4336 DME and supplies
243V A4337 DME and supplies-Vendor
243 A4338 DME and supplies
243 A4340 DME and supplies
243 A4344 DME and supplies
243 A4346 DME and supplies
243 A4349 DME and supplies
243 A4351 DME and supplies
243 A4352 DME and supplies
243 A4353 DME and supplies
243 A4354 DME and supplies
243 A4355 DME and supplies
243 A4356 DME and supplies
243 A4357 DME and supplies
243 A4358 DME and supplies
243 A4360 DME and supplies
243 A4361 DME and supplies
243 A4362 DME and supplies
243 A4363 DME and supplies
243 A4364 DME and supplies
243 A4366 DME and supplies
243 A4367 DME and supplies
243 A4368 DME and supplies
243 A4369 DME and supplies
243 A4371 DME and supplies
243 A4372 DME and supplies
243 A4373 DME and supplies
243 A4375 DME and supplies
243 A4376 DME and supplies
243 A4377 DME and supplies
243 A4378 DME and supplies
243 A4379 DME and supplies
243 A4380 DME and supplies
243 A4381 DME and supplies
243 A4382 DME and supplies
243 A4383 DME and supplies
243 A4384 DME and supplies
243 A4385 DME and supplies
243 A4387 DME and supplies
243 A4388 DME and supplies
243 A4389 DME and supplies
243 A4390 DME and supplies
243 A4391 DME and supplies
243 A4392 DME and supplies
243 A4393 DME and supplies
243 A4394 DME and supplies
243 A4395 DME and supplies
243 A4396 DME and supplies
243 A4397 DME and supplies
243 A4398 DME and supplies
243 A4399 DME and supplies
243 A4400 DME and supplies
243 A4402 DME and supplies
243 A4404 DME and supplies
243 A4405 DME and supplies
243 A4406 DME and supplies
243 A4407 DME and supplies
243 A4408 DME and supplies
243 A4409 DME and supplies
Blue Cross NC Proprietary and Confidential 133 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
243 A4410 DME and supplies
243 A4411 DME and supplies
243 A4412 DME and supplies
243 A4413 DME and supplies
243 A4414 DME and supplies
243 A4415 DME and supplies
243 A4416 DME and supplies
243 A4417 DME and supplies
243 A4418 DME and supplies
243 A4419 DME and supplies
243 A4420 DME and supplies
243 A4421 DME and supplies
243 A4422 DME and supplies
243 A4423 DME and supplies
243 A4424 DME and supplies
243 A4425 DME and supplies
243 A4426 DME and supplies
243 A4427 DME and supplies
243 A4428 DME and supplies
243 A4429 DME and supplies
243 A4430 DME and supplies
243 A4431 DME and supplies
243 A4432 DME and supplies
243 A4433 DME and supplies
243 A4434 DME and supplies
243 A4435 DME and supplies
243 A4450 DME and supplies
243 A4452 DME and supplies
243 A4455 DME and supplies
243V A4456 DME and supplies-Vendor
243V A4458 DME and supplies-Vendor
243V A4459 DME and supplies-Vendor
243 A4461 DME and supplies
243 A4463 DME and supplies
243 A4465 DME and supplies
243 A4467 DME and supplies
243 A4470 DME and supplies
243 A4480 DME and supplies
243 A4481 DME and supplies
243 A4483 DME and supplies
243 A4490 DME and supplies
243 A4495 DME and supplies
243 A4500 DME and supplies
243 A4510 DME and supplies
243 A4520 DME and supplies
243 A4534 DME and supplies
243 A4550 DME and supplies
243 A4553 DME and supplies
243 A4554 DME and supplies
243 A4555 DME and supplies
243V A4556 DME and supplies-Vendor
243V A4557 DME and supplies-Vendor
243V A4558 DME and supplies-Vendor
243V A4559 DME and supplies-Vendor
243 A4561 DME and supplies
243 A4562 DME and supplies
243V A4563 DME and supplies-Vendor
243 A4565 DME and supplies
243 A4566 DME and supplies
243 A4570 DME and supplies
243 A4575 DME and supplies
243 A4580 DME and supplies
243 A4590 DME and supplies
243V A4595 DME and supplies-Vendor
243V A4600 DME and supplies-Vendor
243V A4601 DME and supplies-Vendor
243V A4602 DME and supplies-Vendor
243V A4604 DME and supplies-Vendor
243V A4605 DME and supplies-Vendor
243V A4606 DME and supplies-Vendor
243V A4608 DME and supplies-Vendor
243V A4611 DME and supplies-Vendor
243V A4612 DME and supplies-Vendor
243V A4613 DME and supplies-Vendor
Blue Cross NC Proprietary and Confidential 134 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
243 A4614 DME and supplies
243V A4615 DME and supplies-Vendor
243V A4616 DME and supplies-Vendor
243V A4617 DME and supplies-Vendor
243V A4618 DME and supplies-Vendor
243V A4619 DME and supplies-Vendor
243V A4620 DME and supplies-Vendor
243 A4623 DME and supplies
243 A4624 DME and supplies
243 A4625 DME and supplies
243 A4626 DME and supplies
243 A4627 DME and supplies
243V A4628 DME and supplies-Vendor
243V A4629 DME and supplies-Vendor
243V A4630 DME and supplies-Vendor
243V A4633 DME and supplies-Vendor
243V A4634 DME and supplies-Vendor
243V A4635 DME and supplies-Vendor
243V A4636 DME and supplies-Vendor
243V A4637 DME and supplies-Vendor
243V A4638 DME and supplies-Vendor
243V A4639 DME and supplies-Vendor
243V A4640 DME and supplies-Vendor
243 A4641 DME and supplies
243 A4642 DME and supplies
243 A4648 DME and supplies
243 A4649 DME and supplies
243 A4650 DME and supplies
243V A4651 DME and supplies-Vendor
243V A4652 DME and supplies-Vendor
243V A4653 DME and supplies-Vendor
243V A4657 DME and supplies-Vendor
243V A4660 DME and supplies-Vendor
243V A4663 DME and supplies-Vendor
243V A4670 DME and supplies-Vendor
243V A4671 DME and supplies-Vendor
243V A4672 DME and supplies-Vendor
243V A4673 DME and supplies-Vendor
243V A4674 DME and supplies-Vendor
243V A4680 DME and supplies-Vendor
243V A4690 DME and supplies-Vendor
243V A4706 DME and supplies-Vendor
243V A4707 DME and supplies-Vendor
243V A4708 DME and supplies-Vendor
243V A4709 DME and supplies-Vendor
243V A4714 DME and supplies-Vendor
243V A4719 DME and supplies-Vendor
243V A4720 DME and supplies-Vendor
243V A4721 DME and supplies-Vendor
243V A4722 DME and supplies-Vendor
243V A4723 DME and supplies-Vendor
243V A4724 DME and supplies-Vendor
243V A4725 DME and supplies-Vendor
243V A4726 DME and supplies-Vendor
243V A4728 DME and supplies-Vendor
243V A4730 DME and supplies-Vendor
243V A4736 DME and supplies-Vendor
243V A4737 DME and supplies-Vendor
243V A4740 DME and supplies-Vendor
243V A4750 DME and supplies-Vendor
243V A4755 DME and supplies-Vendor
243V A4760 DME and supplies-Vendor
243V A4765 DME and supplies-Vendor
243V A4766 DME and supplies-Vendor
243V A4770 DME and supplies-Vendor
243V A4771 DME and supplies-Vendor
243V A4772 DME and supplies-Vendor
243V A4773 DME and supplies-Vendor
243V A4774 DME and supplies-Vendor
240 A4802 Medications (Injections, infusions and other forms)
243V A4860 DME and supplies-Vendor
243V A4870 DME and supplies-Vendor
243V A4890 DME and supplies-Vendor
243V A4911 DME and supplies-Vendor
Blue Cross NC Proprietary and Confidential 135 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
243V A4913 DME and supplies-Vendor
243V A4918 DME and supplies-Vendor
243V A4927 DME and supplies-Vendor
243V A4928 DME and supplies-Vendor
243V A4929 DME and supplies-Vendor
243V A4930 DME and supplies-Vendor
243V A4931 DME and supplies-Vendor
243V A4932 DME and supplies-Vendor
243V A5051 DME and supplies-Vendor
243V A5052 DME and supplies-Vendor
243V A5053 DME and supplies-Vendor
243V A5054 DME and supplies-Vendor
243V A5055 DME and supplies-Vendor
243V A5056 DME and supplies-Vendor
243V A5057 DME and supplies-Vendor
243V A5061 DME and supplies-Vendor
243V A5062 DME and supplies-Vendor
243V A5063 DME and supplies-Vendor
243V A5071 DME and supplies-Vendor
243V A5072 DME and supplies-Vendor
243V A5073 DME and supplies-Vendor
243V A5081 DME and supplies-Vendor
243V A5082 DME and supplies-Vendor
243V A5083 DME and supplies-Vendor
243V A5093 DME and supplies-Vendor
243V A5102 DME and supplies-Vendor
243V A5105 DME and supplies-Vendor
243V A5112 DME and supplies-Vendor
243V A5113 DME and supplies-Vendor
243V A5114 DME and supplies-Vendor
243V A5120 DME and supplies-Vendor
243V A5121 DME and supplies-Vendor
243V A5122 DME and supplies-Vendor
243V A5126 DME and supplies-Vendor
243V A5131 DME and supplies-Vendor
243V A5200 DME and supplies-Vendor
243 A5500 DME and supplies
243 A5501 DME and supplies
243 A5503 DME and supplies
243 A5504 DME and supplies
243V A5505 DME and supplies-Vendor
243V A5506 DME and supplies-Vendor
243V A5507 DME and supplies-Vendor
243V A5508 DME and supplies-Vendor
243V A5510 DME and supplies-Vendor
243V A5512 DME and supplies-Vendor
243V A5513 DME and supplies-Vendor
243 A5514 DME and supplies
243V A6000 DME and supplies-Vendor
243 A6010 DME and supplies
243 A6011 DME and supplies
243 A6021 DME and supplies
243 A6022 DME and supplies
243 A6023 DME and supplies
243 A6024 DME and supplies
243 A6025 DME and supplies
243 A6154 DME and supplies
243 A6196 DME and supplies
243 A6197 DME and supplies
243 A6198 DME and supplies
243 A6199 DME and supplies
243 A6203 DME and supplies
243 A6204 DME and supplies
243 A6205 DME and supplies
243 A6206 DME and supplies
243 A6207 DME and supplies
243 A6208 DME and supplies
243 A6209 DME and supplies
243 A6210 DME and supplies
243 A6211 DME and supplies
243 A6212 DME and supplies
243 A6213 DME and supplies
243 A6214 DME and supplies
243 A6215 DME and supplies
Blue Cross NC Proprietary and Confidential 136 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
243 A6216 DME and supplies
243 A6217 DME and supplies
243 A6218 DME and supplies
243 A6219 DME and supplies
243 A6220 DME and supplies
243 A6221 DME and supplies
243 A6222 DME and supplies
243 A6223 DME and supplies
243 A6224 DME and supplies
243 A6228 DME and supplies
243 A6229 DME and supplies
243 A6230 DME and supplies
243 A6231 DME and supplies
243 A6232 DME and supplies
243 A6233 DME and supplies
243 A6234 DME and supplies
243 A6235 DME and supplies
243 A6236 DME and supplies
243 A6237 DME and supplies
243 A6238 DME and supplies
243 A6239 DME and supplies
243 A6240 DME and supplies
243 A6241 DME and supplies
243 A6242 DME and supplies
243 A6243 DME and supplies
243 A6244 DME and supplies
243 A6245 DME and supplies
243 A6246 DME and supplies
243 A6247 DME and supplies
243 A6248 DME and supplies
243 A6250 DME and supplies
243 A6251 DME and supplies
243 A6252 DME and supplies
243 A6253 DME and supplies
243 A6254 DME and supplies
243 A6255 DME and supplies
243 A6256 DME and supplies
243 A6257 DME and supplies
243 A6258 DME and supplies
243 A6259 DME and supplies
243 A6260 DME and supplies
243 A6261 DME and supplies
243 A6262 DME and supplies
243 A6266 DME and supplies
243 A6402 DME and supplies
243 A6403 DME and supplies
243 A6404 DME and supplies
243 A6407 DME and supplies
243 A6410 DME and supplies
243 A6411 DME and supplies
243 A6412 DME and supplies
243 A6413 DME and supplies
243 A6441 DME and supplies
243 A6442 DME and supplies
243 A6443 DME and supplies
243 A6444 DME and supplies
243 A6445 DME and supplies
243 A6446 DME and supplies
243 A6447 DME and supplies
243 A6448 DME and supplies
243 A6449 DME and supplies
243 A6450 DME and supplies
243 A6451 DME and supplies
243 A6452 DME and supplies
243 A6453 DME and supplies
243 A6454 DME and supplies
243 A6455 DME and supplies
243 A6456 DME and supplies
243 A6457 DME and supplies
243V A6460 DME and supplies-Vendor
243V A6461 DME and supplies-Vendor
243 A6501 DME and supplies
243 A6502 DME and supplies
243 A6503 DME and supplies
Blue Cross NC Proprietary and Confidential 137 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
243 A6504 DME and supplies
243 A6505 DME and supplies
243 A6506 DME and supplies
243 A6507 DME and supplies
243 A6508 DME and supplies
243 A6509 DME and supplies
243 A6510 DME and supplies
243 A6511 DME and supplies
243 A6512 DME and supplies
243 A6513 DME and supplies
243 A6530 DME and supplies
243 A6531 DME and supplies
243 A6532 DME and supplies
243 A6533 DME and supplies
243 A6534 DME and supplies
243 A6535 DME and supplies
243 A6536 DME and supplies
243 A6537 DME and supplies
243 A6538 DME and supplies
243 A6539 DME and supplies
243 A6540 DME and supplies
243 A6541 DME and supplies
243 A6544 DME and supplies
243 A6545 DME and supplies
243 A6549 DME and supplies
243V A6550 DME and supplies-Vendor
243V A7000 DME and supplies-Vendor
243V A7001 DME and supplies-Vendor
243V A7002 DME and supplies-Vendor
243V A7003 DME and supplies-Vendor
243 A7004 DME and supplies
243 A7005 DME and supplies
243 A7006 DME and supplies
243V A7007 DME and supplies-Vendor
243V A7008 DME and supplies-Vendor
243V A7009 DME and supplies-Vendor
243V A7010 DME and supplies-Vendor
243V A7012 DME and supplies-Vendor
243V A7013 DME and supplies-Vendor
243V A7014 DME and supplies-Vendor
243 A7015 DME and supplies
243 A7016 DME and supplies
243V A7017 DME and supplies-Vendor
243V A7018 DME and supplies-Vendor
243V A7020 DME and supplies-Vendor
243V A7025 DME and supplies-Vendor
243V A7026 DME and supplies-Vendor
243V A7027 DME and supplies-Vendor
243V A7028 DME and supplies-Vendor
243V A7029 DME and supplies-Vendor
243V A7030 DME and supplies-Vendor
243V A7031 DME and supplies-Vendor
243V A7032 DME and supplies-Vendor
243V A7033 DME and supplies-Vendor
243V A7034 DME and supplies-Vendor
243V A7035 DME and supplies-Vendor
243V A7036 DME and supplies-Vendor
243V A7037 DME and supplies-Vendor
243V A7038 DME and supplies-Vendor
243V A7039 DME and supplies-Vendor
243 A7040 DME and supplies
243 A7041 DME and supplies
243V A7044 DME and supplies-Vendor
243V A7045 DME and supplies-Vendor
243V A7046 DME and supplies-Vendor
243V A7047 DME and supplies-Vendor
243V A7048 DME and supplies-Vendor
243 A7501 DME and supplies
243 A7502 DME and supplies
243 A7503 DME and supplies
243 A7504 DME and supplies
243 A7505 DME and supplies
243 A7506 DME and supplies
243 A7507 DME and supplies
Blue Cross NC Proprietary and Confidential 138 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
243 A7508 DME and supplies
243 A7509 DME and supplies
243 A7520 DME and supplies
243 A7521 DME and supplies
243 A7522 DME and supplies
243 A7523 DME and supplies
243 A7524 DME and supplies
243 A7525 DME and supplies
243 A7526 DME and supplies
243 A7527 DME and supplies
243V A8000 DME and supplies-Vendor
243V A8001 DME and supplies-Vendor
243V A8002 DME and supplies-Vendor
243V A8003 DME and supplies-Vendor
243V A8004 DME and supplies-Vendor
243 A9150 DME and supplies
243 A9152 DME and supplies
243 A9153 DME and supplies
243 A9155 DME and supplies
243 A9180 DME and supplies
243 A9270 DME and supplies
243V A9272 DME and supplies-Vendor
243V A9273 DME and supplies-Vendor
243 A9274 DME and supplies
243 A9275 DME and supplies
243 A9276 DME and supplies
243 A9277 DME and supplies
243 A9278 DME and supplies
243V A9279 DME and supplies-Vendor
243V A9280 DME and supplies-Vendor
243 A9281 DME and supplies
243V A9282 DME and supplies-Vendor
243V A9283 DME and supplies-Vendor
243V A9284 DME and supplies-Vendor
243V A9285 DME and supplies-Vendor
243 A9286 DME and supplies
243V A9300 DME and supplies-Vendor
243 A9500 DME and supplies
243 A9501 DME and supplies
243 A9502 DME and supplies
243 A9503 DME and supplies
243 A9504 DME and supplies
243 A9505 DME and supplies
243 A9507 DME and supplies
243 A9508 DME and supplies
243 A9509 DME and supplies
243 A9510 DME and supplies
243 A9512 DME and supplies
211 A9513 Therapeutic Radiology
243 A9515 DME and supplies
243 A9516 DME and supplies
243 A9517 DME and supplies
243 A9520 DME and supplies
243 A9521 DME and supplies
243 A9524 DME and supplies
243 A9526 DME and supplies
243 A9527 DME and supplies
243 A9528 DME and supplies
243 A9529 DME and supplies
243 A9530 DME and supplies
243 A9531 DME and supplies
243 A9532 DME and supplies
243 A9536 DME and supplies
243 A9537 DME and supplies
243 A9538 DME and supplies
243 A9539 DME and supplies
243 A9540 DME and supplies
243 A9541 DME and supplies
243 A9542 DME and supplies
243 A9543 DME and supplies
243 A9546 DME and supplies
243 A9547 DME and supplies
243 A9548 DME and supplies
243 A9550 DME and supplies
Blue Cross NC Proprietary and Confidential 139 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
243 A9551 DME and supplies
243V A9552 DME and supplies-Vendor
243 A9553 DME and supplies
243 A9554 DME and supplies
243 A9555 DME and supplies
243 A9556 DME and supplies
243 A9557 DME and supplies
243 A9558 DME and supplies
243 A9559 DME and supplies
243 A9560 DME and supplies
243 A9561 DME and supplies
243 A9562 DME and supplies
243 A9563 DME and supplies
243 A9564 DME and supplies
243 A9566 DME and supplies
243 A9567 DME and supplies
243 A9568 DME and supplies
243 A9569 DME and supplies
243 A9570 DME and supplies
243 A9571 DME and supplies
243 A9572 DME and supplies
240 A9575 Medications (Injections, infusions and other forms)
243 A9576 DME and supplies
243 A9577 DME and supplies
243 A9578 DME and supplies
243 A9579 DME and supplies
243 A9580 DME and supplies
240 A9581 Medications (Injections, infusions and other forms)
240 A9582 Medications (Injections, infusions and other forms)
240 A9583 Medications (Injections, infusions and other forms)
243 A9584 DME and supplies
243 A9585 DME and supplies
243V A9586 DME and supplies-Vendor
243V A9587 DME and supplies-Vendor
243V A9588 DME and supplies-Vendor
240 A9589 Medications (Injections, infusions and other forms)
240 A9590 Medications (Injections, infusions and other forms)
243V A9597 DME and supplies-Vendor
243V A9598 DME and supplies-Vendor
243 A9600 DME and supplies
240 A9604 Medications (Injections, infusions and other forms)
243 A9606 DME and supplies
243 A9698 DME and supplies
243 A9699 DME and supplies
243 A9700 DME and supplies
243 A9900 DME and supplies
243 A9901 DME and supplies
243 A9999 DME and supplies
243 B4034 DME and supplies
243 B4035 DME and supplies
243 B4036 DME and supplies
243 B4081 DME and supplies
243 B4082 DME and supplies
243 B4083 DME and supplies
243 B4087 DME and supplies
243 B4088 DME and supplies
243 B4100 DME and supplies
243 B4102 DME and supplies
243 B4103 DME and supplies
243 B4104 DME and supplies
243V B4105 DME and supplies-Vendor
243 B4149 DME and supplies
243 B4150 DME and supplies
243 B4152 DME and supplies
243 B4153 DME and supplies
243 B4154 DME and supplies
243 B4155 DME and supplies
243 B4157 DME and supplies
243 B4158 DME and supplies
243 B4159 DME and supplies
243 B4160 DME and supplies
243 B4161 DME and supplies
243 B4162 DME and supplies
243 B4164 DME and supplies
Blue Cross NC Proprietary and Confidential 140 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
243 B4168 DME and supplies
243 B4172 DME and supplies
243 B4176 DME and supplies
243 B4178 DME and supplies
243 B4180 DME and supplies
243 B4185 DME and supplies
243 B4187 DME and Supplies
243 B4189 DME and supplies
243 B4193 DME and supplies
243 B4197 DME and supplies
243 B4199 DME and supplies
243 B4216 DME and supplies
243 B4220 DME and supplies
243 B4222 DME and supplies
243 B4224 DME and supplies
243 B5000 DME and supplies
243 B5100 DME and supplies
243 B5200 DME and supplies
243V B9002 DME and supplies-Vendor
243V B9004 DME and supplies-Vendor
243V B9006 DME and supplies-Vendor
243 B9998 DME and supplies
243 B9999 DME and supplies
29 D0120 Oral And Dental Services
29 D0140 Oral And Dental Services
29 D0145 Oral And Dental Services
29 D0150 Oral And Dental Services
29 D0160 Oral And Dental Services
29 D0170 Oral And Dental Services
29 D0171 Oral And Dental Services
29 D0180 Oral And Dental Services
29 D0190 Oral And Dental Services
29 D0191 Oral And Dental Services
29 D0210 Oral And Dental Services
29 D0220 Oral And Dental Services
29 D0230 Oral And Dental Services
29 D0240 Oral And Dental Services
29 D0250 Oral And Dental Services
29 D0251 Oral And Dental Services
29 D0270 Oral And Dental Services
29 D0272 Oral And Dental Services
29 D0273 Oral And Dental Services
29 D0274 Oral And Dental Services
29 D0277 Oral And Dental Services
29 D0310 Oral And Dental Services
29 D0320 Oral And Dental Services
29 D0321 Oral And Dental Services
29 D0322 Oral And Dental Services
29 D0330 Oral And Dental Services
29 D0340 Oral And Dental Services
29 D0350 Oral And Dental Services
29 D0351 Oral And Dental Services
29 D0364 Oral And Dental Services
29 D0365 Oral And Dental Services
29 D0366 Oral And Dental Services
29 D0367 Oral And Dental Services
29 D0368 Oral And Dental Services
29 D0369 Oral And Dental Services
29 D0370 Oral And Dental Services
29 D0371 Oral And Dental Services
29 D0380 Oral And Dental Services
29 D0381 Oral And Dental Services
29 D0382 Oral And Dental Services
29 D0383 Oral And Dental Services
29 D0384 Oral And Dental Services
29 D0385 Oral And Dental Services
29 D0386 Oral And Dental Services
29 D0391 Oral And Dental Services
29 D0393 Oral And Dental Services
29 D0394 Oral And Dental Services
29 D0395 Oral And Dental Services
29 D0411 Oral And Dental Services
233 D0412 Laboratory - Chemistry And Hematology
29 D0414 Oral And Dental Services
Blue Cross NC Proprietary and Confidential 141 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
29 D0415 Oral And Dental Services
29 D0416 Oral And Dental Services
29 D0417 Oral And Dental Services
29 D0418 Oral And Dental Services
29 D0419 Oral And Dental Services
29 D0422 Oral And Dental Services
29 D0423 Oral And Dental Services
29 D0425 Oral And Dental Services
29 D0431 Oral And Dental Services
29 D0460 Oral And Dental Services
29 D0470 Oral And Dental Services
29 D0472 Oral And Dental Services
29 D0473 Oral And Dental Services
29 D0474 Oral And Dental Services
29 D0475 Oral And Dental Services
29 D0476 Oral And Dental Services
29 D0477 Oral And Dental Services
29 D0478 Oral And Dental Services
29 D0479 Oral And Dental Services
29 D0480 Oral And Dental Services
29 D0481 Oral And Dental Services
29 D0482 Oral And Dental Services
29 D0483 Oral And Dental Services
29 D0484 Oral And Dental Services
29 D0485 Oral And Dental Services
29 D0486 Oral And Dental Services
29 D0502 Oral And Dental Services
29 D0600 Oral And Dental Services
29 D0601 Oral And Dental Services
29 D0602 Oral And Dental Services
29 D0603 Oral And Dental Services
29 D0999 Oral And Dental Services
29 D1110 Oral And Dental Services
29 D1120 Oral And Dental Services
29 D1206 Oral And Dental Services
29 D1208 Oral And Dental Services
29 D1310 Oral And Dental Services
29 D1320 Oral And Dental Services
29 D1330 Oral And Dental Services
29 D1351 Oral And Dental Services
29 D1352 Oral And Dental Services
29 D1353 Oral And Dental Services
29 D1354 Oral And Dental Services
29 D1510 Oral And Dental Services
29 D1516 Oral And Dental Services
29 D1517 Oral And Dental Services
29 D1520 Oral And Dental Services
29 D1526 Oral And Dental Services
29 D1527 Oral And Dental Services
29 D1551 Oral And Dental Services
29 D1552 Oral And Dental Services
29 D1553 Oral And Dental Services
29 D1556 Oral And Dental Services
29 D1557 Oral And Dental Services
29 D1558 Oral And Dental Services
29 D1575 Oral And Dental Services
29 D1999 Oral And Dental Services
29 D2140 Oral And Dental Services
29 D2150 Oral And Dental Services
29 D2160 Oral And Dental Services
29 D2161 Oral And Dental Services
29 D2330 Oral And Dental Services
29 D2331 Oral And Dental Services
29 D2332 Oral And Dental Services
29 D2335 Oral And Dental Services
29 D2390 Oral And Dental Services
29 D2391 Oral And Dental Services
29 D2392 Oral And Dental Services
29 D2393 Oral And Dental Services
29 D2394 Oral And Dental Services
29 D2410 Oral And Dental Services
29 D2420 Oral And Dental Services
29 D2430 Oral And Dental Services
29 D2510 Oral And Dental Services
Blue Cross NC Proprietary and Confidential 142 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
29 D2520 Oral And Dental Services
29 D2530 Oral And Dental Services
29 D2542 Oral And Dental Services
29 D2543 Oral And Dental Services
29 D2544 Oral And Dental Services
29 D2610 Oral And Dental Services
29 D2620 Oral And Dental Services
29 D2630 Oral And Dental Services
29 D2642 Oral And Dental Services
29 D2643 Oral And Dental Services
29 D2644 Oral And Dental Services
29 D2650 Oral And Dental Services
29 D2651 Oral And Dental Services
29 D2652 Oral And Dental Services
29 D2662 Oral And Dental Services
29 D2663 Oral And Dental Services
29 D2664 Oral And Dental Services
29 D2710 Oral And Dental Services
29 D2712 Oral And Dental Services
29 D2720 Oral And Dental Services
29 D2721 Oral And Dental Services
29 D2722 Oral And Dental Services
29 D2740 Oral And Dental Services
29 D2750 Oral And Dental Services
29 D2751 Oral And Dental Services
29 D2752 Oral And Dental Services
29 D2753 Oral And Dental Services
29 D2780 Oral And Dental Services
29 D2781 Oral And Dental Services
29 D2782 Oral And Dental Services
29 D2783 Oral And Dental Services
29 D2790 Oral And Dental Services
29 D2791 Oral And Dental Services
29 D2792 Oral And Dental Services
29 D2794 Oral And Dental Services
29 D2799 Oral And Dental Services
29 D2910 Oral And Dental Services
29 D2915 Oral And Dental Services
29 D2920 Oral And Dental Services
29 D2921 Oral And Dental Services
29 D2929 Oral And Dental Services
29 D2930 Oral And Dental Services
29 D2931 Oral And Dental Services
29 D2932 Oral And Dental Services
29 D2933 Oral And Dental Services
29 D2934 Oral And Dental Services
29 D2940 Oral And Dental Services
29 D2941 Oral And Dental Services
29 D2949 Oral And Dental Services
29 D2950 Oral And Dental Services
29 D2951 Oral And Dental Services
29 D2952 Oral And Dental Services
29 D2953 Oral And Dental Services
29 D2954 Oral And Dental Services
29 D2955 Oral And Dental Services
29 D2957 Oral And Dental Services
29 D2960 Oral And Dental Services
29 D2961 Oral And Dental Services
29 D2962 Oral And Dental Services
29 D2971 Oral And Dental Services
29 D2975 Oral And Dental Services
29 D2980 Oral And Dental Services
29 D2981 Oral And Dental Services
29 D2982 Oral And Dental Services
29 D2983 Oral And Dental Services
29 D2990 Oral And Dental Services
29 D2999 Oral And Dental Services
29 D3110 Oral And Dental Services
29 D3120 Oral And Dental Services
29 D3220 Oral And Dental Services
29 D3221 Oral And Dental Services
29 D3222 Oral And Dental Services
29 D3230 Oral And Dental Services
29 D3240 Oral And Dental Services
Blue Cross NC Proprietary and Confidential 143 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
29 D3310 Oral And Dental Services
29 D3320 Oral And Dental Services
29 D3330 Oral And Dental Services
29 D3331 Oral And Dental Services
29 D3332 Oral And Dental Services
29 D3333 Oral And Dental Services
29 D3346 Oral And Dental Services
29 D3347 Oral And Dental Services
29 D3348 Oral And Dental Services
29 D3351 Oral And Dental Services
29 D3352 Oral And Dental Services
29 D3353 Oral And Dental Services
29 D3355 Oral And Dental Services
29 D3356 Oral And Dental Services
29 D3357 Oral And Dental Services
29 D3410 Oral And Dental Services
29 D3421 Oral And Dental Services
29 D3425 Oral And Dental Services
29 D3426 Oral And Dental Services
29 D3427 Oral And Dental Services
29 D3428 Oral And Dental Services
29 D3429 Oral And Dental Services
29 D3430 Oral And Dental Services
29 D3431 Oral And Dental Services
29 D3432 Oral And Dental Services
29 D3450 Oral And Dental Services
29 D3460 Oral And Dental Services
29 D3470 Oral And Dental Services
29 D3910 Oral And Dental Services
29 D3920 Oral And Dental Services
29 D3950 Oral And Dental Services
29 D3999 Oral And Dental Services
29 D4210 Oral And Dental Services
29 D4211 Oral And Dental Services
29 D4212 Oral And Dental Services
29 D4230 Oral And Dental Services
29 D4231 Oral And Dental Services
29 D4240 Oral And Dental Services
29 D4241 Oral And Dental Services
29 D4245 Oral And Dental Services
29 D4249 Oral And Dental Services
29 D4260 Oral And Dental Services
29 D4261 Oral And Dental Services
29 D4263 Oral And Dental Services
29 D4264 Oral And Dental Services
29 D4265 Oral And Dental Services
29 D4266 Oral And Dental Services
29 D4267 Oral And Dental Services
29 D4268 Oral And Dental Services
29 D4270 Oral And Dental Services
29 D4273 Oral And Dental Services
29 D4274 Oral And Dental Services
29 D4275 Oral And Dental Services
29 D4276 Oral And Dental Services
29 D4277 Oral And Dental Services
29 D4278 Oral And Dental Services
29 D4283 Oral And Dental Services
29 D4285 Oral And Dental Services
29 D4320 Oral And Dental Services
29 D4321 Oral And Dental Services
29 D4341 Oral And Dental Services
29 D4342 Oral And Dental Services
29 D4346 Oral And Dental Services
29 D4355 Oral And Dental Services
29 D4381 Oral And Dental Services
29 D4910 Oral And Dental Services
29 D4920 Oral And Dental Services
29 D4921 Oral And Dental Services
29 D4999 Oral And Dental Services
29 D5110 Oral And Dental Services
29 D5120 Oral And Dental Services
29 D5130 Oral And Dental Services
29 D5140 Oral And Dental Services
29 D5211 Oral And Dental Services
Blue Cross NC Proprietary and Confidential 144 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
29 D5212 Oral And Dental Services
29 D5213 Oral And Dental Services
29 D5214 Oral And Dental Services
29 D5221 Oral And Dental Services
29 D5222 Oral And Dental Services
29 D5223 Oral And Dental Services
29 D5224 Oral And Dental Services
29 D5225 Oral And Dental Services
29 D5226 Oral And Dental Services
29 D5282 Oral And Dental Services
29 D5283 Oral And Dental Services
29 D5284 Oral And Dental Services
29 D5286 Oral And Dental Services
29 D5410 Oral And Dental Services
29 D5411 Oral And Dental Services
29 D5421 Oral And Dental Services
29 D5422 Oral And Dental Services
29 D5511 Oral And Dental Services
29 D5512 Oral And Dental Services
29 D5520 Oral And Dental Services
29 D5611 Oral And Dental Services
29 D5612 Oral And Dental Services
29 D5621 Oral And Dental Services
29 D5622 Oral And Dental Services
29 D5630 Oral And Dental Services
29 D5640 Oral And Dental Services
29 D5650 Oral And Dental Services
29 D5660 Oral And Dental Services
29 D5670 Oral And Dental Services
29 D5671 Oral And Dental Services
29 D5710 Oral And Dental Services
29 D5711 Oral And Dental Services
29 D5720 Oral And Dental Services
29 D5721 Oral And Dental Services
29 D5730 Oral And Dental Services
29 D5731 Oral And Dental Services
29 D5740 Oral And Dental Services
29 D5741 Oral And Dental Services
29 D5750 Oral And Dental Services
29 D5751 Oral And Dental Services
29 D5760 Oral And Dental Services
29 D5761 Oral And Dental Services
29 D5810 Oral And Dental Services
29 D5811 Oral And Dental Services
29 D5820 Oral And Dental Services
29 D5821 Oral And Dental Services
29 D5850 Oral And Dental Services
29 D5851 Oral And Dental Services
29 D5862 Oral And Dental Services
29 D5863 Oral And Dental Services
29 D5864 Oral And Dental Services
29 D5865 Oral And Dental Services
29 D5866 Oral And Dental Services
29 D5867 Oral And Dental Services
29 D5875 Oral And Dental Services
29 D5876 Oral And Dental Services
29 D5899 Oral And Dental Services
29 D5911 Oral And Dental Services
29 D5912 Oral And Dental Services
29 D5913 Oral And Dental Services
29 D5914 Oral And Dental Services
29 D5915 Oral And Dental Services
29 D5916 Oral And Dental Services
29 D5919 Oral And Dental Services
29 D5922 Oral And Dental Services
29 D5923 Oral And Dental Services
29 D5924 Oral And Dental Services
29 D5925 Oral And Dental Services
29 D5926 Oral And Dental Services
29 D5927 Oral And Dental Services
29 D5928 Oral And Dental Services
29 D5929 Oral And Dental Services
29 D5931 Oral And Dental Services
29 D5932 Oral And Dental Services
Blue Cross NC Proprietary and Confidential 145 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
29 D5933 Oral And Dental Services
29 D5934 Oral And Dental Services
29 D5935 Oral And Dental Services
29 D5936 Oral And Dental Services
29 D5937 Oral And Dental Services
29 D5951 Oral And Dental Services
29 D5952 Oral And Dental Services
29 D5953 Oral And Dental Services
29 D5954 Oral And Dental Services
29 D5955 Oral And Dental Services
29 D5958 Oral And Dental Services
29 D5959 Oral And Dental Services
29 D5960 Oral And Dental Services
29 D5982 Oral And Dental Services
29 D5983 Oral And Dental Services
29 D5984 Oral And Dental Services
29 D5985 Oral And Dental Services
29 D5986 Oral And Dental Services
29 D5987 Oral And Dental Services
29 D5988 Oral And Dental Services
29 D5991 Oral And Dental Services
29 D5992 Oral And Dental Services
29 D5993 Oral And Dental Services
29 D5994 Oral And Dental Services
29 D5999 Oral And Dental Services
29 D6010 Oral And Dental Services
29 D6011 Oral And Dental Services
29 D6012 Oral And Dental Services
29 D6013 Oral And Dental Services
29 D6040 Oral And Dental Services
29 D6050 Oral And Dental Services
29 D6051 Oral And Dental Services
29 D6052 Oral And Dental Services
29 D6055 Oral And Dental Services
29 D6056 Oral And Dental Services
29 D6057 Oral And Dental Services
29 D6058 Oral And Dental Services
29 D6059 Oral And Dental Services
29 D6060 Oral And Dental Services
29 D6061 Oral And Dental Services
29 D6062 Oral And Dental Services
29 D6063 Oral And Dental Services
29 D6064 Oral And Dental Services
29 D6065 Oral And Dental Services
29 D6066 Oral And Dental Services
29 D6067 Oral And Dental Services
29 D6068 Oral And Dental Services
29 D6069 Oral And Dental Services
29 D6070 Oral And Dental Services
29 D6071 Oral And Dental Services
29 D6072 Oral And Dental Services
29 D6073 Oral And Dental Services
29 D6074 Oral And Dental Services
29 D6075 Oral And Dental Services
29 D6076 Oral And Dental Services
29 D6077 Oral And Dental Services
29 D6080 Oral And Dental Services
29 D6081 Oral And Dental Services
29 D6082 Oral And Dental Services
29 D6083 Oral And Dental Services
29 D6084 Oral And Dental Services
29 D6085 Oral And Dental Services
29 D6086 Oral And Dental Services
29 D6087 Oral And Dental Services
29 D6088 Oral And Dental Services
29 D6090 Oral And Dental Services
29 D6091 Oral And Dental Services
29 D6092 Oral And Dental Services
29 D6093 Oral And Dental Services
29 D6094 Oral And Dental Services
29 D6095 Oral And Dental Services
29 D6096 Oral And Dental Services
29 D6097 Oral And Dental Services
29 D6098 Oral And Dental Services
Blue Cross NC Proprietary and Confidential 146 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
29 D6099 Oral And Dental Services
29 D6100 Oral And Dental Services
29 D6101 Oral And Dental Services
29 D6102 Oral And Dental Services
29 D6103 Oral And Dental Services
29 D6104 Oral And Dental Services
29 D6110 Oral And Dental Services
29 D6111 Oral And Dental Services
29 D6112 Oral And Dental Services
29 D6113 Oral And Dental Services
29 D6114 Oral And Dental Services
29 D6115 Oral And Dental Services
29 D6116 Oral And Dental Services
29 D6117 Oral And Dental Services
29 D6118 Oral And Dental Services
29 D6119 Oral And Dental Services
29 D6120 Oral And Dental Services
29 D6121 Oral And Dental Services
29 D6122 Oral And Dental Services
29 D6123 Oral And Dental Services
29 D6190 Oral And Dental Services
29 D6194 Oral And Dental Services
29 D6195 Oral And Dental Services
29 D6199 Oral And Dental Services
29 D6205 Oral And Dental Services
29 D6210 Oral And Dental Services
29 D6211 Oral And Dental Services
29 D6212 Oral And Dental Services
29 D6214 Oral And Dental Services
29 D6240 Oral And Dental Services
29 D6241 Oral And Dental Services
29 D6242 Oral And Dental Services
29 D6243 Oral And Dental Services
29 D6245 Oral And Dental Services
29 D6250 Oral And Dental Services
29 D6251 Oral And Dental Services
29 D6252 Oral And Dental Services
29 D6253 Oral And Dental Services
29 D6545 Oral And Dental Services
29 D6548 Oral And Dental Services
29 D6549 Oral And Dental Services
29 D6600 Oral And Dental Services
29 D6601 Oral And Dental Services
29 D6602 Oral And Dental Services
29 D6603 Oral And Dental Services
29 D6604 Oral And Dental Services
29 D6605 Oral And Dental Services
29 D6606 Oral And Dental Services
29 D6607 Oral And Dental Services
29 D6608 Oral And Dental Services
29 D6609 Oral And Dental Services
29 D6610 Oral And Dental Services
29 D6611 Oral And Dental Services
29 D6612 Oral And Dental Services
29 D6613 Oral And Dental Services
29 D6614 Oral And Dental Services
29 D6615 Oral And Dental Services
29 D6624 Oral And Dental Services
29 D6634 Oral And Dental Services
29 D6710 Oral And Dental Services
29 D6720 Oral And Dental Services
29 D6721 Oral And Dental Services
29 D6722 Oral And Dental Services
29 D6740 Oral And Dental Services
29 D6750 Oral And Dental Services
29 D6751 Oral And Dental Services
29 D6752 Oral And Dental Services
29 D6753 Oral And Dental Services
29 D6780 Oral And Dental Services
29 D6781 Oral And Dental Services
29 D6782 Oral And Dental Services
29 D6783 Oral And Dental Services
29 D6784 Oral And Dental Services
29 D6790 Oral And Dental Services
Blue Cross NC Proprietary and Confidential 147 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
29 D6791 Oral And Dental Services
29 D6792 Oral And Dental Services
29 D6793 Oral And Dental Services
29 D6794 Oral And Dental Services
29 D6920 Oral And Dental Services
29 D6930 Oral And Dental Services
29 D6940 Oral And Dental Services
29 D6950 Oral And Dental Services
29 D6980 Oral And Dental Services
29 D6985 Oral And Dental Services
29 D6999 Oral And Dental Services
29 D7111 Oral And Dental Services
29 D7140 Oral And Dental Services
29 D7210 Oral And Dental Services
29 D7220 Oral And Dental Services
29 D7230 Oral And Dental Services
29 D7240 Oral And Dental Services
29 D7241 Oral And Dental Services
29 D7250 Oral And Dental Services
29 D7251 Oral And Dental Services
29 D7260 Oral And Dental Services
29 D7261 Oral And Dental Services
29 D7270 Oral And Dental Services
29 D7272 Oral And Dental Services
29 D7280 Oral And Dental Services
29 D7282 Oral And Dental Services
29 D7283 Oral And Dental Services
29 D7285 Oral And Dental Services
29 D7286 Oral And Dental Services
29 D7287 Oral And Dental Services
29 D7288 Oral And Dental Services
29 D7290 Oral And Dental Services
29 D7291 Oral And Dental Services
29 D7292 Oral And Dental Services
29 D7293 Oral And Dental Services
29 D7294 Oral And Dental Services
29 D7295 Oral And Dental Services
29 D7296 Oral And Dental Services
29 D7297 Oral And Dental Services
29 D7310 Oral And Dental Services
29 D7311 Oral And Dental Services
29 D7320 Oral And Dental Services
29 D7321 Oral And Dental Services
29 D7340 Oral And Dental Services
29 D7350 Oral And Dental Services
29 D7410 Oral And Dental Services
29 D7411 Oral And Dental Services
29 D7412 Oral And Dental Services
29 D7413 Oral And Dental Services
29 D7414 Oral And Dental Services
29 D7415 Oral And Dental Services
29 D7440 Oral And Dental Services
29 D7441 Oral And Dental Services
29 D7450 Oral And Dental Services
29 D7451 Oral And Dental Services
29 D7460 Oral And Dental Services
29 D7461 Oral And Dental Services
29 D7465 Oral And Dental Services
29 D7471 Oral And Dental Services
29 D7472 Oral And Dental Services
29 D7473 Oral And Dental Services
29 D7485 Oral And Dental Services
29 D7490 Oral And Dental Services
29 D7510 Oral And Dental Services
29 D7511 Oral And Dental Services
29 D7520 Oral And Dental Services
29 D7521 Oral And Dental Services
29 D7530 Oral And Dental Services
29 D7540 Oral And Dental Services
29 D7550 Oral And Dental Services
29 D7560 Oral And Dental Services
29 D7610 Oral And Dental Services
29 D7620 Oral And Dental Services
29 D7630 Oral And Dental Services
Blue Cross NC Proprietary and Confidential 148 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
29 D7640 Oral And Dental Services
29 D7650 Oral And Dental Services
29 D7660 Oral And Dental Services
29 D7670 Oral And Dental Services
29 D7671 Oral And Dental Services
29 D7680 Oral And Dental Services
29 D7710 Oral And Dental Services
29 D7720 Oral And Dental Services
29 D7730 Oral And Dental Services
29 D7740 Oral And Dental Services
29 D7750 Oral And Dental Services
29 D7760 Oral And Dental Services
29 D7770 Oral And Dental Services
29 D7771 Oral And Dental Services
29 D7780 Oral And Dental Services
29 D7810 Oral And Dental Services
29 D7820 Oral And Dental Services
29 D7830 Oral And Dental Services
29 D7840 Oral And Dental Services
29 D7850 Oral And Dental Services
29 D7852 Oral And Dental Services
29 D7854 Oral And Dental Services
29 D7856 Oral And Dental Services
29 D7858 Oral And Dental Services
29 D7860 Oral And Dental Services
29 D7865 Oral And Dental Services
29 D7870 Oral And Dental Services
29 D7871 Oral And Dental Services
29 D7872 Oral And Dental Services
29 D7873 Oral And Dental Services
29 D7874 Oral And Dental Services
29 D7875 Oral And Dental Services
29 D7876 Oral And Dental Services
29 D7877 Oral And Dental Services
29 D7880 Oral And Dental Services
29 D7881 Oral And Dental Services
29 D7899 Oral And Dental Services
29 D7910 Oral And Dental Services
29 D7911 Oral And Dental Services
29 D7912 Oral And Dental Services
29 D7920 Oral And Dental Services
29 D7921 Oral And Dental Services
29 D7922 Oral And Dental Services
29 D7940 Oral And Dental Services
29 D7941 Oral And Dental Services
29 D7943 Oral And Dental Services
29 D7944 Oral And Dental Services
29 D7945 Oral And Dental Services
29 D7946 Oral And Dental Services
29 D7947 Oral And Dental Services
29 D7948 Oral And Dental Services
29 D7949 Oral And Dental Services
29 D7950 Oral And Dental Services
29 D7951 Oral And Dental Services
29 D7952 Oral And Dental Services
29 D7953 Oral And Dental Services
29 D7955 Oral And Dental Services
29 D7960 Oral And Dental Services
29 D7963 Oral And Dental Services
29 D7970 Oral And Dental Services
29 D7971 Oral And Dental Services
29 D7972 Oral And Dental Services
29 D7979 Oral And Dental Services
29 D7980 Oral And Dental Services
29 D7981 Oral And Dental Services
29 D7982 Oral And Dental Services
29 D7983 Oral And Dental Services
29 D7990 Oral And Dental Services
29 D7991 Oral And Dental Services
29 D7995 Oral And Dental Services
29 D7996 Oral And Dental Services
29 D7997 Oral And Dental Services
29 D7998 Oral And Dental Services
29 D7999 Oral And Dental Services
Blue Cross NC Proprietary and Confidential 149 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
29 D8010 Oral And Dental Services
29 D8020 Oral And Dental Services
29 D8030 Oral And Dental Services
29 D8040 Oral And Dental Services
29 D8050 Oral And Dental Services
29 D8060 Oral And Dental Services
29 D8070 Oral And Dental Services
29 D8080 Oral And Dental Services
29 D8090 Oral And Dental Services
29 D8210 Oral And Dental Services
29 D8220 Oral And Dental Services
29 D8660 Oral And Dental Services
29 D8670 Oral And Dental Services
29 D8680 Oral And Dental Services
29 D8681 Oral And Dental Services
29 D8690 Oral And Dental Services
29 D8695 Oral And Dental Services
29 D8696 Oral And Dental Services
29 D8697 Oral And Dental Services
29 D8698 Oral And Dental Services
29 D8699 Oral And Dental Services
29 D8701 Oral And Dental Services
29 D8702 Oral And Dental Services
29 D8703 Oral And Dental Services
29 D8704 Oral And Dental Services
29 D8999 Oral And Dental Services
29 D9110 Oral And Dental Services
29 D9120 Oral And Dental Services
29 D9130 Oral And Dental Services
29 D9210 Oral And Dental Services
29 D9211 Oral And Dental Services
29 D9212 Oral And Dental Services
29 D9215 Oral And Dental Services
29 D9219 Oral And Dental Services
29 D9222 Oral And Dental Services
29 D9223 Oral And Dental Services
29 D9230 Oral And Dental Services
29 D9239 Oral And Dental Services
29 D9243 Oral And Dental Services
29 D9248 Oral And Dental Services
29 D9310 Oral And Dental Services
29 D9311 Oral And Dental Services
29 D9410 Oral And Dental Services
29 D9420 Oral And Dental Services
29 D9430 Oral And Dental Services
29 D9440 Oral And Dental Services
29 D9450 Oral And Dental Services
29 D9610 Oral And Dental Services
29 D9612 Oral And Dental Services
29 D9613 Oral And Dental Services
29 D9630 Oral And Dental Services
29 D9910 Oral And Dental Services
29 D9911 Oral And Dental Services
29 D9920 Oral And Dental Services
29 D9930 Oral And Dental Services
29 D9932 Oral And Dental Services
29 D9933 Oral And Dental Services
29 D9934 Oral And Dental Services
29 D9935 Oral And Dental Services
29 D9941 Oral And Dental Services
29 D9942 Oral And Dental Services
29 D9943 Oral And Dental Services
29 D9944 Oral And Dental Services
29 D9945 Oral And Dental Services
29 D9946 Oral And Dental Services
29 D9950 Oral And Dental Services
29 D9951 Oral And Dental Services
29 D9952 Oral And Dental Services
29 D9961 Oral And Dental Services
29 D9970 Oral And Dental Services
29 D9971 Oral And Dental Services
29 D9972 Oral And Dental Services
29 D9973 Oral And Dental Services
29 D9974 Oral And Dental Services
Blue Cross NC Proprietary and Confidential 150 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
29 D9975 Oral And Dental Services
29 D9985 Oral And Dental Services
29 D9986 Oral And Dental Services
29 D9987 Oral And Dental Services
29 D9990 Oral And Dental Services
29 D9991 Oral And Dental Services
29 D9992 Oral And Dental Services
29 D9993 Oral And Dental Services
29 D9994 Oral And Dental Services
29 D9995 Oral And Dental Services
29 D9996 Oral And Dental Services
29 D9997 Oral And Dental Services
29 D9999 Oral And Dental Services
243 E0100 DME and supplies
243 E0105 DME and supplies
243 E0110 DME and supplies
243 E0111 DME and supplies
243 E0112 DME and supplies
243 E0113 DME and supplies
243 E0114 DME and supplies
243 E0116 DME and supplies
243 E0117 DME and supplies
243 E0130 DME and supplies
243 E0135 DME and supplies
243 E0140 DME and supplies
243 E0141 DME and supplies
243 E0143 DME and supplies
243 E0144 DME and supplies
243 E0147 DME and supplies
243 E0148 DME and supplies
243 E0149 DME and supplies
243 E0153 DME and supplies
243 E0154 DME and supplies
243 E0155 DME and supplies
243 E0156 DME and supplies
243 E0157 DME and supplies
243 E0158 DME and supplies
243 E0159 DME and supplies
243V E0160 DME and supplies-Vendor
243V E0161 DME and supplies-Vendor
243V E0162 DME and supplies-Vendor
243V E0163 DME and supplies-Vendor
243V E0165 DME and supplies-Vendor
243V E0167 DME and supplies-Vendor
243V E0168 DME and supplies-Vendor
243V E0170 DME and supplies-Vendor
243V E0171 DME and supplies-Vendor
243V E0172 DME and supplies-Vendor
243V E0175 DME and supplies-Vendor
243V E0181 DME and supplies-Vendor
243V E0182 DME and supplies-Vendor
243V E0184 DME and supplies-Vendor
243V E0185 DME and supplies-Vendor
243V E0186 DME and supplies-Vendor
243V E0187 DME and supplies-Vendor
243V E0188 DME and supplies-Vendor
243V E0189 DME and supplies-Vendor
243V E0190 DME and supplies-Vendor
243V E0191 DME and supplies-Vendor
243V E0193 DME and supplies-Vendor
243V E0194 DME and supplies-Vendor
243V E0196 DME and supplies-Vendor
243V E0197 DME and supplies-Vendor
243V E0198 DME and supplies-Vendor
243V E0199 DME and supplies-Vendor
243V E0200 DME and supplies-Vendor
243V E0203 DME and supplies-Vendor
243V E0205 DME and supplies-Vendor
243V E0210 DME and supplies-Vendor
243V E0215 DME and supplies-Vendor
243V E0217 DME and supplies-Vendor
243V E0218 DME and supplies-Vendor
243V E0221 DME and supplies-Vendor
243V E0225 DME and supplies-Vendor
Blue Cross NC Proprietary and Confidential 151 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
243V E0231 DME and supplies-Vendor
243V E0232 DME and supplies-Vendor
243V E0235 DME and supplies-Vendor
243V E0236 DME and supplies-Vendor
243V E0239 DME and supplies-Vendor
243V E0240 DME and supplies-Vendor
243V E0241 DME and supplies-Vendor
243V E0242 DME and supplies-Vendor
243V E0243 DME and supplies-Vendor
243V E0244 DME and supplies-Vendor
243V E0245 DME and supplies-Vendor
243V E0246 DME and supplies-Vendor
243V E0247 DME and supplies-Vendor
243V E0248 DME and supplies-Vendor
243V E0249 DME and supplies-Vendor
243V E0250 DME and supplies-Vendor
243V E0251 DME and supplies-Vendor
243V E0255 DME and supplies-Vendor
243V E0256 DME and supplies-Vendor
243V E0260 DME and supplies-Vendor
243V E0261 DME and supplies-Vendor
243V E0265 DME and supplies-Vendor
243V E0266 DME and supplies-Vendor
243V E0270 DME and supplies-Vendor
243V E0271 DME and supplies-Vendor
243V E0272 DME and supplies-Vendor
243V E0273 DME and supplies-Vendor
243V E0274 DME and supplies-Vendor
243V E0275 DME and supplies-Vendor
243V E0276 DME and supplies-Vendor
243V E0277 DME and supplies-Vendor
243V E0280 DME and supplies-Vendor
243V E0290 DME and supplies-Vendor
243V E0291 DME and supplies-Vendor
243V E0292 DME and supplies-Vendor
243V E0293 DME and supplies-Vendor
243V E0294 DME and supplies-Vendor
243V E0295 DME and supplies-Vendor
243V E0296 DME and supplies-Vendor
243V E0297 DME and supplies-Vendor
243V E0300 DME and supplies-Vendor
243V E0301 DME and supplies-Vendor
243V E0302 DME and supplies-Vendor
243V E0303 DME and supplies-Vendor
243V E0304 DME and supplies-Vendor
243V E0305 DME and supplies-Vendor
243V E0310 DME and supplies-Vendor
243V E0315 DME and supplies-Vendor
243V E0316 DME and supplies-Vendor
243V E0325 DME and supplies-Vendor
243V E0326 DME and supplies-Vendor
243V E0328 DME and supplies-Vendor
243V E0329 DME and supplies-Vendor
243V E0350 DME and supplies-Vendor
243V E0352 DME and supplies-Vendor
243V E0370 DME and supplies-Vendor
243V E0371 DME and supplies-Vendor
243V E0372 DME and supplies-Vendor
243V E0373 DME and supplies-Vendor
243V E0424 DME and supplies-Vendor
243V E0425 DME and supplies-Vendor
243V E0430 DME and supplies-Vendor
243V E0431 DME and supplies-Vendor
243V E0433 DME and supplies-Vendor
243V E0434 DME and supplies-Vendor
243V E0435 DME and supplies-Vendor
243V E0439 DME and supplies-Vendor
243V E0440 DME and supplies-Vendor
243V E0441 DME and supplies-Vendor
243V E0442 DME and supplies-Vendor
243V E0443 DME and supplies-Vendor
243V E0444 DME and supplies-Vendor
243V E0445 DME and supplies-Vendor
243V E0446 DME and supplies-Vendor
Blue Cross NC Proprietary and Confidential 152 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
243V E0447 DME and supplies-Vendor
243V E0455 DME and supplies-Vendor
243V E0457 DME and supplies-Vendor
243V E0459 DME and supplies-Vendor
243V E0462 DME and supplies-Vendor
243V E0467 DME and supplies-Vendor
243V E0470 DME and supplies-Vendor
243V E0471 DME and supplies-Vendor
243V E0472 DME and supplies-Vendor
243V E0480 DME and supplies-Vendor
243V E0481 DME and supplies-Vendor
243V E0482 DME and supplies-Vendor
243V E0483 DME and supplies-Vendor
243V E0484 DME and supplies-Vendor
243V E0485 DME and supplies-Vendor
243V E0486 DME and supplies-Vendor
243V E0487 DME and supplies-Vendor
243V E0500 DME and supplies-Vendor
243V E0550 DME and supplies-Vendor
243V E0555 DME and supplies-Vendor
243V E0560 DME and supplies-Vendor
243V E0561 DME and supplies-Vendor
243V E0562 DME and supplies-Vendor
243V E0565 DME and supplies-Vendor
243V E0570 DME and supplies-Vendor
243V E0572 DME and supplies-Vendor
243V E0574 DME and supplies-Vendor
243V E0575 DME and supplies-Vendor
243V E0580 DME and supplies-Vendor
243V E0585 DME and supplies-Vendor
243V E0600 DME and supplies-Vendor
243V E0601 DME and supplies-Vendor
243V E0602 DME and supplies-Vendor
243V E0603 DME and supplies-Vendor
243V E0604 DME and supplies-Vendor
243V E0605 DME and supplies-Vendor
243V E0606 DME and supplies-Vendor
243V E0607 DME and supplies-Vendor
243V E0610 DME and supplies-Vendor
243V E0615 DME and supplies-Vendor
243V E0616 DME and supplies-Vendor
243V E0617 DME and supplies-Vendor
243V E0618 DME and supplies-Vendor
243V E0620 DME and supplies-Vendor
243V E0621 DME and supplies-Vendor
243V E0625 DME and supplies-Vendor
243V E0627 DME and supplies-Vendor
243V E0629 DME and supplies-Vendor
243V E0630 DME and supplies-Vendor
243V E0635 DME and supplies-Vendor
243V E0636 DME and supplies-Vendor
243V E0637 DME and supplies-Vendor
243V E0638 DME and supplies-Vendor
243V E0639 DME and supplies-Vendor
243V E0640 DME and supplies-Vendor
243V E0641 DME and supplies-Vendor
243V E0642 DME and supplies-Vendor
243V E0650 DME and supplies-Vendor
243V E0651 DME and supplies-Vendor
243V E0652 DME and supplies-Vendor
243V E0655 DME and supplies-Vendor
243V E0656 DME and supplies-Vendor
243V E0657 DME and supplies-Vendor
243V E0660 DME and supplies-Vendor
243V E0665 DME and supplies-Vendor
243V E0666 DME and supplies-Vendor
243V E0667 DME and supplies-Vendor
243V E0668 DME and supplies-Vendor
243V E0669 DME and supplies-Vendor
243V E0670 DME and supplies-Vendor
243V E0671 DME and supplies-Vendor
243V E0672 DME and supplies-Vendor
243V E0673 DME and supplies-Vendor
243V E0675 DME and supplies-Vendor
Blue Cross NC Proprietary and Confidential 153 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
243V E0676 DME and supplies-Vendor
243V E0691 DME and supplies-Vendor
243V E0692 DME and supplies-Vendor
243V E0693 DME and supplies-Vendor
243V E0694 DME and supplies-Vendor
243V E0700 DME and supplies-Vendor
243V E0705 DME and supplies-Vendor
243V E0710 DME and supplies-Vendor
243V E0720 DME and supplies-Vendor
243V E0730 DME and supplies-Vendor
243V E0731 DME and supplies-Vendor
243V E0740 DME and supplies-Vendor
243V E0744 DME and supplies-Vendor
243V E0745 DME and supplies-Vendor
243V E0746 DME and supplies-Vendor
243V E0747 DME and supplies-Vendor
243V E0748 DME and supplies-Vendor
243V E0749 DME and supplies-Vendor
243V E0755 DME and supplies-Vendor
243V E0760 DME and supplies-Vendor
243V E0761 DME and supplies-Vendor
243V E0762 DME and supplies-Vendor
243V E0764 DME and supplies-Vendor
243V E0765 DME and supplies-Vendor
243V E0766 DME and supplies-Vendor
243V E0769 DME and supplies-Vendor
243V E0770 DME and supplies-Vendor
243V E0776 DME and supplies-Vendor
243V E0779 DME and supplies-Vendor
243V E0780 DME and supplies-Vendor
243V E0781 DME and supplies-Vendor
243V E0782 DME and supplies-Vendor
243V E0783 DME and supplies-Vendor
243V E0784 DME and supplies-Vendor
243 E0785 DME and supplies
243V E0786 DME and supplies-Vendor
243V E0787 DME and supplies-Vendor
243V E0791 DME and supplies-Vendor
243V E0830 DME and supplies-Vendor
243V E0840 DME and supplies-Vendor
243V E0849 DME and supplies-Vendor
243V E0850 DME and supplies-Vendor
243V E0855 DME and supplies-Vendor
243V E0856 DME and supplies-Vendor
243V E0860 DME and supplies-Vendor
243V E0870 DME and supplies-Vendor
243V E0880 DME and supplies-Vendor
243V E0890 DME and supplies-Vendor
243V E0900 DME and supplies-Vendor
243V E0910 DME and supplies-Vendor
243V E0911 DME and supplies-Vendor
243V E0912 DME and supplies-Vendor
243V E0920 DME and supplies-Vendor
243V E0930 DME and supplies-Vendor
243V E0935 DME and supplies-Vendor
243V E0936 DME and supplies-Vendor
243V E0940 DME and supplies-Vendor
243V E0941 DME and supplies-Vendor
243V E0942 DME and supplies-Vendor
243V E0944 DME and supplies-Vendor
243V E0945 DME and supplies-Vendor
243V E0946 DME and supplies-Vendor
243V E0947 DME and supplies-Vendor
243V E0948 DME and supplies-Vendor
243V E0950 DME and supplies-Vendor
243V E0951 DME and supplies-Vendor
243V E0952 DME and supplies-Vendor
243V E0953 DME and supplies-Vendor
243V E0954 DME and supplies-Vendor
243V E0955 DME and supplies-Vendor
243V E0956 DME and supplies-Vendor
243V E0957 DME and supplies-Vendor
243V E0958 DME and supplies-Vendor
243V E0959 DME and supplies-Vendor
Blue Cross NC Proprietary and Confidential 154 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
243V E0960 DME and supplies-Vendor
243V E0961 DME and supplies-Vendor
243V E0966 DME and supplies-Vendor
243V E0967 DME and supplies-Vendor
243V E0968 DME and supplies-Vendor
243V E0969 DME and supplies-Vendor
243V E0970 DME and supplies-Vendor
243V E0971 DME and supplies-Vendor
243V E0973 DME and supplies-Vendor
243V E0974 DME and supplies-Vendor
243V E0978 DME and supplies-Vendor
243V E0980 DME and supplies-Vendor
243V E0981 DME and supplies-Vendor
243V E0982 DME and supplies-Vendor
243V E0983 DME and supplies-Vendor
243V E0984 DME and supplies-Vendor
243V E0985 DME and supplies-Vendor
243V E0986 DME and supplies-Vendor
243V E0988 DME and supplies-Vendor
243V E0990 DME and supplies-Vendor
243V E0992 DME and supplies-Vendor
243V E0994 DME and supplies-Vendor
243V E0995 DME and supplies-Vendor
243V E1002 DME and supplies-Vendor
243V E1003 DME and supplies-Vendor
243V E1004 DME and supplies-Vendor
243V E1005 DME and supplies-Vendor
243V E1006 DME and supplies-Vendor
243V E1007 DME and supplies-Vendor
243V E1008 DME and supplies-Vendor
243V E1009 DME and supplies-Vendor
243V E1010 DME and supplies-Vendor
243V E1011 DME and supplies-Vendor
243V E1012 DME and supplies-Vendor
243V E1014 DME and supplies-Vendor
243V E1015 DME and supplies-Vendor
243V E1016 DME and supplies-Vendor
243V E1017 DME and supplies-Vendor
243V E1018 DME and supplies-Vendor
243V E1019 DME and supplies-Vendor
243V E1020 DME and supplies-Vendor
243V E1021 DME and supplies-Vendor
243V E1028 DME and supplies-Vendor
243V E1029 DME and supplies-Vendor
243V E1030 DME and supplies-Vendor
243V E1031 DME and supplies-Vendor
243V E1035 DME and supplies-Vendor
243V E1036 DME and supplies-Vendor
243V E1037 DME and supplies-Vendor
243V E1038 DME and supplies-Vendor
243V E1039 DME and supplies-Vendor
243V E1050 DME and supplies-Vendor
243V E1060 DME and supplies-Vendor
243V E1070 DME and supplies-Vendor
243V E1083 DME and supplies-Vendor
243V E1084 DME and supplies-Vendor
243V E1085 DME and supplies-Vendor
243V E1086 DME and supplies-Vendor
243V E1087 DME and supplies-Vendor
243V E1088 DME and supplies-Vendor
243V E1089 DME and supplies-Vendor
243V E1090 DME and supplies-Vendor
243V E1092 DME and supplies-Vendor
243V E1093 DME and supplies-Vendor
243V E1100 DME and supplies-Vendor
243V E1110 DME and supplies-Vendor
243V E1130 DME and supplies-Vendor
243V E1140 DME and supplies-Vendor
243V E1150 DME and supplies-Vendor
243V E1160 DME and supplies-Vendor
243V E1161 DME and supplies-Vendor
243V E1170 DME and supplies-Vendor
243V E1171 DME and supplies-Vendor
243V E1172 DME and supplies-Vendor
Blue Cross NC Proprietary and Confidential 155 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
243V E1180 DME and supplies-Vendor
243V E1190 DME and supplies-Vendor
243V E1195 DME and supplies-Vendor
243V E1200 DME and supplies-Vendor
243V E1211 DME and supplies-Vendor
243V E1213 DME and supplies-Vendor
243V E1220 DME and supplies-Vendor
243V E1221 DME and supplies-Vendor
243V E1222 DME and supplies-Vendor
243V E1223 DME and supplies-Vendor
243V E1224 DME and supplies-Vendor
243V E1225 DME and supplies-Vendor
243V E1226 DME and supplies-Vendor
243V E1227 DME and supplies-Vendor
243V E1228 DME and supplies-Vendor
243V E1229 DME and supplies-Vendor
243V E1230 DME and supplies-Vendor
243V E1231 DME and supplies-Vendor
243V E1232 DME and supplies-Vendor
243V E1233 DME and supplies-Vendor
243V E1234 DME and supplies-Vendor
243V E1235 DME and supplies-Vendor
243V E1236 DME and supplies-Vendor
243V E1237 DME and supplies-Vendor
243V E1238 DME and supplies-Vendor
243V E1239 DME and supplies-Vendor
243V E1240 DME and supplies-Vendor
243V E1250 DME and supplies-Vendor
243V E1260 DME and supplies-Vendor
243V E1270 DME and supplies-Vendor
243V E1280 DME and supplies-Vendor
243V E1285 DME and supplies-Vendor
243V E1290 DME and supplies-Vendor
243V E1295 DME and supplies-Vendor
243V E1296 DME and supplies-Vendor
243V E1297 DME and supplies-Vendor
243V E1298 DME and supplies-Vendor
243V E1300 DME and supplies-Vendor
243V E1310 DME and supplies-Vendor
243V E1352 DME and supplies-Vendor
243V E1353 DME and supplies-Vendor
243V E1354 DME and supplies-Vendor
243V E1355 DME and supplies-Vendor
243V E1356 DME and supplies-Vendor
243V E1357 DME and supplies-Vendor
243V E1358 DME and supplies-Vendor
243V E1372 DME and supplies-Vendor
243V E1390 DME and supplies-Vendor
243V E1391 DME and supplies-Vendor
243V E1392 DME and supplies-Vendor
243V E1399 DME and supplies-Vendor
243V E1405 DME and supplies-Vendor
243V E1406 DME and supplies-Vendor
243V E1500 DME and supplies-Vendor
243V E1510 DME and supplies-Vendor
243V E1520 DME and supplies-Vendor
243V E1530 DME and supplies-Vendor
243V E1540 DME and supplies-Vendor
243V E1550 DME and supplies-Vendor
243V E1560 DME and supplies-Vendor
243V E1570 DME and supplies-Vendor
243V E1575 DME and supplies-Vendor
243V E1580 DME and supplies-Vendor
243V E1590 DME and supplies-Vendor
243V E1592 DME and supplies-Vendor
243V E1594 DME and supplies-Vendor
243V E1600 DME and supplies-Vendor
243V E1610 DME and supplies-Vendor
243V E1615 DME and supplies-Vendor
243V E1620 DME and supplies-Vendor
243V E1625 DME and supplies-Vendor
243V E1630 DME and supplies-Vendor
243V E1632 DME and supplies-Vendor
243V E1634 DME and supplies-Vendor
Blue Cross NC Proprietary and Confidential 156 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
243V E1635 DME and supplies-Vendor
243V E1636 DME and supplies-Vendor
243V E1637 DME and supplies-Vendor
243V E1639 DME and supplies-Vendor
243V E1699 DME and supplies-Vendor
243V E1700 DME and supplies-Vendor
243V E1701 DME and supplies-Vendor
243V E1702 DME and supplies-Vendor
243V E1802 DME and supplies-Vendor
243V E1805 DME and supplies-Vendor
243V E1806 DME and supplies-Vendor
243V E1811 DME and supplies-Vendor
243V E1815 DME and supplies-Vendor
243V E1816 DME and supplies-Vendor
243V E1818 DME and supplies-Vendor
243V E1825 DME and supplies-Vendor
243V E1830 DME and supplies-Vendor
243V E1831 DME and supplies-Vendor
243V E1840 DME and supplies-Vendor
243V E1841 DME and supplies-Vendor
243V E1902 DME and supplies-Vendor
243V E2000 DME and supplies-Vendor
243V E2100 DME and supplies-Vendor
243V E2101 DME and supplies-Vendor
243V E2120 DME and supplies-Vendor
243V E2201 DME and supplies-Vendor
243V E2202 DME and supplies-Vendor
243V E2203 DME and supplies-Vendor
243V E2204 DME and supplies-Vendor
243V E2205 DME and supplies-Vendor
243V E2206 DME and supplies-Vendor
243V E2207 DME and supplies-Vendor
243V E2208 DME and supplies-Vendor
243V E2209 DME and supplies-Vendor
243V E2210 DME and supplies-Vendor
243V E2211 DME and supplies-Vendor
243V E2212 DME and supplies-Vendor
243V E2213 DME and supplies-Vendor
243V E2214 DME and supplies-Vendor
243V E2215 DME and supplies-Vendor
243V E2216 DME and supplies-Vendor
243V E2217 DME and supplies-Vendor
243V E2218 DME and supplies-Vendor
243V E2219 DME and supplies-Vendor
243V E2220 DME and supplies-Vendor
243V E2221 DME and supplies-Vendor
243V E2222 DME and supplies-Vendor
243V E2224 DME and supplies-Vendor
243V E2225 DME and supplies-Vendor
243V E2226 DME and supplies-Vendor
243V E2227 DME and supplies-Vendor
243V E2228 DME and supplies-Vendor
243V E2230 DME and supplies-Vendor
243V E2231 DME and supplies-Vendor
243V E2291 DME and supplies-Vendor
243V E2292 DME and supplies-Vendor
243V E2293 DME and supplies-Vendor
243V E2294 DME and supplies-Vendor
243V E2295 DME and supplies-Vendor
243V E2300 DME and supplies-Vendor
243V E2301 DME and supplies-Vendor
243V E2310 DME and supplies-Vendor
243V E2311 DME and supplies-Vendor
243V E2312 DME and supplies-Vendor
243V E2313 DME and supplies-Vendor
243V E2321 DME and supplies-Vendor
243V E2322 DME and supplies-Vendor
243V E2323 DME and supplies-Vendor
243V E2324 DME and supplies-Vendor
243V E2325 DME and supplies-Vendor
243V E2326 DME and supplies-Vendor
243V E2327 DME and supplies-Vendor
243V E2328 DME and supplies-Vendor
243V E2329 DME and supplies-Vendor
Blue Cross NC Proprietary and Confidential 157 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
243V E2330 DME and supplies-Vendor
243V E2331 DME and supplies-Vendor
243V E2340 DME and supplies-Vendor
243V E2341 DME and supplies-Vendor
243V E2342 DME and supplies-Vendor
243V E2343 DME and supplies-Vendor
243V E2351 DME and supplies-Vendor
243V E2358 DME and supplies-Vendor
243V E2359 DME and supplies-Vendor
243V E2360 DME and supplies-Vendor
243V E2361 DME and supplies-Vendor
243V E2362 DME and supplies-Vendor
243V E2363 DME and supplies-Vendor
243V E2364 DME and supplies-Vendor
243V E2365 DME and supplies-Vendor
243V E2366 DME and supplies-Vendor
243V E2367 DME and supplies-Vendor
243V E2368 DME and supplies-Vendor
243V E2369 DME and supplies-Vendor
243V E2370 DME and supplies-Vendor
243V E2371 DME and supplies-Vendor
243V E2372 DME and supplies-Vendor
243V E2373 DME and supplies-Vendor
243V E2374 DME and supplies-Vendor
243V E2375 DME and supplies-Vendor
243V E2376 DME and supplies-Vendor
243V E2377 DME and supplies-Vendor
243V E2378 DME and supplies-Vendor
243V E2381 DME and supplies-Vendor
243V E2382 DME and supplies-Vendor
243V E2383 DME and supplies-Vendor
243V E2384 DME and supplies-Vendor
243V E2385 DME and supplies-Vendor
243V E2386 DME and supplies-Vendor
243V E2387 DME and supplies-Vendor
243V E2388 DME and supplies-Vendor
243V E2389 DME and supplies-Vendor
243V E2390 DME and supplies-Vendor
243V E2391 DME and supplies-Vendor
243V E2392 DME and supplies-Vendor
243V E2394 DME and supplies-Vendor
243V E2395 DME and supplies-Vendor
243V E2396 DME and supplies-Vendor
243V E2397 DME and supplies-Vendor
243V E2398 DME and supplies-Vendor
243V E2500 DME and supplies-Vendor
243V E2502 DME and supplies-Vendor
243V E2504 DME and supplies-Vendor
243V E2506 DME and supplies-Vendor
243V E2508 DME and supplies-Vendor
243V E2510 DME and supplies-Vendor
243V E2511 DME and supplies-Vendor
243V E2512 DME and supplies-Vendor
243V E2599 DME and supplies-Vendor
243V E2601 DME and supplies-Vendor
243V E2602 DME and supplies-Vendor
243V E2603 DME and supplies-Vendor
243V E2604 DME and supplies-Vendor
243V E2605 DME and supplies-Vendor
243V E2606 DME and supplies-Vendor
243V E2607 DME and supplies-Vendor
243V E2608 DME and supplies-Vendor
243V E2609 DME and supplies-Vendor
243V E2610 DME and supplies-Vendor
243V E2611 DME and supplies-Vendor
243V E2612 DME and supplies-Vendor
243V E2613 DME and supplies-Vendor
243V E2614 DME and supplies-Vendor
243V E2615 DME and supplies-Vendor
243V E2616 DME and supplies-Vendor
243V E2617 DME and supplies-Vendor
243V E2619 DME and supplies-Vendor
243V E2620 DME and supplies-Vendor
243V E2621 DME and supplies-Vendor
Blue Cross NC Proprietary and Confidential 158 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
243V E2622 DME and supplies-Vendor
243V E2623 DME and supplies-Vendor
243V E2624 DME and supplies-Vendor
243V E2625 DME and supplies-Vendor
243V E2626 DME and supplies-Vendor
243V E2627 DME and supplies-Vendor
243V E2628 DME and supplies-Vendor
243V E2629 DME and supplies-Vendor
243V E2630 DME and supplies-Vendor
243V E2631 DME and supplies-Vendor
243V E2632 DME and supplies-Vendor
243V E2633 DME and supplies-Vendor
243V E8000 DME and supplies-Vendor
243V E8001 DME and supplies-Vendor
243V E8002 DME and supplies-Vendor
O1G G0008 Immunizations/Vaccinations
O1G G0009 Immunizations/Vaccinations
O1G G0010 Immunizations/Vaccinations
235 G0027 Other Laboratory
236 G0068 Home Health Services
236 G0069 Home Health Services
236 G0070 Home Health Services
227 G0071 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
236 G0076 Home Health Services
236 G0077 Home Health Services
236 G0078 Home Health Services
236 G0079 Home Health Services
236 G0080 Home Health Services
236 G0081 Home Health Services
236 G0082 Home Health Services
236 G0083 Home Health Services
236 G0084 Home Health Services
236 G0085 Home Health Services
236 G0086 Home Health Services
236 G0087 Home Health Services
130 G0101 Other Diagnostic Procedures, Female Organs
116 G0102 Diagnostic Procedures, Male Genital
233 G0103 Laboratory - Chemistry And Hematology
77 G0104 Proctoscopy And Anorectal Biopsy
76 G0105 Colonoscopy And Biopsy
186 G0106 Lower Gastrointestinal X-Ray
237 G0108 Ancillary Services
237 G0109 Ancillary Services
220 G0117 Ophthalmologic And Otologic Diagnosis And Treatment
220 G0118 Ophthalmologic And Otologic Diagnosis And Treatment
186 G0120 Lower Gastrointestinal X-Ray
76 G0121 Colonoscopy And Biopsy
186 G0122 Lower Gastrointestinal X-Ray
130 G0123 Other Diagnostic Procedures, Female Organs
234 G0124 Pathology
174 G0127 Other Non-Or Therapeutic Procedures On Skin And Breast
237 G0128 Ancillary Services
213 G0129 Physical Therapy Exercises, Manipulation, And Other Procedures
226 G0130 Other Diagnostic Radiology And Related Techniques
234 G0141 Pathology
234 G0143 Pathology
234 G0144 Pathology
234 G0145 Pathology
234 G0147 Pathology
234 G0148 Pathology
236 G0151 Home Health Services
236 G0152 Home Health Services
236 G0153 Home Health Services
236 G0155 Home Health Services
236 G0156 Home Health Services
236 G0159 Home Health Services
236 G0160 Home Health Services
236 G0161 Home Health Services
236 G0162 Home Health Services
63 G0166 Other Non-Or Therapeutic Cardiovascular Procedures
174 G0168 Other Non-Or Therapeutic Procedures On Skin And Breast
237 G0175 Ancillary Services
237 G0176 Ancillary Services
237 G0177 Ancillary Services
Blue Cross NC Proprietary and Confidential 159 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
237 G0179 Ancillary Services
237 G0180 Ancillary Services
237 G0181 Ancillary Services
237 G0182 Ancillary Services
17 G0186 Destruction Of Lesion Of Retina And Choroid
209 G0219 Radioisotope Scan And Function Studies
210 G0235 Other Radioisotope Scan
217 G0237 Other Respiratory Therapy
217 G0238 Other Respiratory Therapy
217 G0239 Other Respiratory Therapy
M1A G0245 Office Visits - New
M1B G0246 Office Visits - Established
M1B G0247 Office Visits - Established
237 G0248 Ancillary Services
243 G0249 DME and supplies
M1B G0250 Office Visits - Established
I2D G0252 Advanced Imaging - MRI, Other
7 G0255 Other Diagnostic Nervous System Procedures
58 G0257 Hemodialysis
156 G0259 Injections And Aspirations Of Muscles, Tendons, Bursa, Joints And Soft Tissue
156 G0260 Injections And Aspirations Of Muscles, Tendons, Bursa, Joints And Soft Tissue
25 G0268 Diagnostic Procedures On Ear
61 G0269 Other Or Procedures On Vessels Other Than Head And Neck
237 G0270 Ancillary Services
237 G0271 Ancillary Services
3 G0276 Laminectomy, Excision Intervertebral Disc
231 G0277 Other Therapeutic Procedures
54 G0278 Other Vascular Catheterization, Not Heart
182 G0279 Mammography
174 G0281 Other Non-Or Therapeutic Procedures On Skin And Breast
174 G0282 Other Non-Or Therapeutic Procedures On Skin And Breast
174 G0283 Other Non-Or Therapeutic Procedures On Skin And Breast
189 G0288 Contrast Aortogram
149 G0289 Arthroscopy
231 G0293 Other Therapeutic Procedures
231 G0294 Other Therapeutic Procedures
174 G0295 Other Non-Or Therapeutic Procedures On Skin And Breast
M6 G0296 OP Consultations
178 G0297 Ct Scan Chest
237 G0299 Ancillary Services
237 G0300 Ancillary Services
36 G0302 Lobectomy Or Pneumonectomy
36 G0303 Lobectomy Or Pneumonectomy
36 G0304 Lobectomy Or Pneumonectomy
36 G0305 Lobectomy Or Pneumonectomy
233 G0306 Laboratory - Chemistry And Hematology
233 G0307 Laboratory - Chemistry And Hematology
235 G0328 Other Laboratory
174 G0329 Other Non-Or Therapeutic Procedures On Skin And Breast
240 G0333 Medications (Injections, infusions and other forms)
237 G0337 Ancillary Services
211 G0339 Therapeutic Radiology
211 G0340 Therapeutic Radiology
176 G0341 Other Organ Transplantation
176 G0342 Other Organ Transplantation
176 G0343 Other Organ Transplantation
237 G0372 Ancillary Services
237 G0378 Ancillary Services
237 G0379 Ancillary Services
M3 G0380 Emergency Room Visit
M3 G0381 Emergency Room Visit
M3 G0382 Emergency Room Visit
M3 G0383 Emergency Room Visit
M3 G0384 Emergency Room Visit
M3 G0390 Emergency Room Visit
219 G0396 Alcohol And Drug Rehabilitation/Detoxification
219 G0397 Alcohol And Drug Rehabilitation/Detoxification
227 G0398 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 G0399 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 G0400 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
M1A G0402 Office Visits - New
202 G0403 Electrocardiogram
202 G0404 Electrocardiogram
202 G0405 Electrocardiogram
Blue Cross NC Proprietary and Confidential 160 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
M6 G0406 IP Consultations
M6 G0407 IP Consultations
M6 G0408 IP Consultations
218 G0409 Psychological And Psychiatric Evaluation And Therapy
218 G0410 Psychological And Psychiatric Evaluation And Therapy
218 G0411 Psychological And Psychiatric Evaluation And Therapy
148 G0412 Other Fracture And Dislocation Procedure
148 G0413 Other Fracture And Dislocation Procedure
148 G0414 Other Fracture And Dislocation Procedure
148 G0415 Other Fracture And Dislocation Procedure
116 G0416 Diagnostic Procedures, Male Genital
237 G0420 Ancillary Services
237 G0421 Ancillary Services
213 G0422 Physical Therapy Exercises, Manipulation, And Other Procedures
213 G0423 Physical Therapy Exercises, Manipulation, And Other Procedures
217 G0424 Other Respiratory Therapy
M6 G0425 IP Consultations
M6 G0426 IP Consultations
M6 G0427 IP Consultations
152 G0428 Arthroplasty Knee
174 G0429 Other Non-Or Therapeutic Procedures On Skin And Breast
233 G0432 Laboratory - Chemistry And Hematology
233 G0433 Laboratory - Chemistry And Hematology
233 G0435 Laboratory - Chemistry And Hematology
227 G0438 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 G0439 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
219 G0442 Alcohol And Drug Rehabilitation/Detoxification
219 G0443 Alcohol And Drug Rehabilitation/Detoxification
218 G0444 Psychological And Psychiatric Evaluation And Therapy
227 G0445 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 G0446 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 G0447 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
48 G0448 Insertion, Revision, Replacement, Removal Of Cardiac Pacemaker Or Cardioverter/Defibrillator
227 G0451 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 G0452 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
7 G0453 Other Diagnostic Nervous System Procedures
227 G0454 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
95 G0455 Other Non-Or Lower GI Therapeutic Procedures
P7A G0458 Oncology - Radiation Therapy
227 G0459 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
231 G0460 Other Therapeutic Procedures
M1B G0463 Office Visits - Established
M1A G0466 Office Visits - New
M1B G0467 Office Visits - Established
M1B G0468 Office Visits - Established
227 G0469 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 G0470 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
T1A G0471 Lab Tests - Routine Venipuncture (Non-Medicare Fee Schedule)
235 G0472 Other Laboratory
M1B G0473 Office Visits - Established
206 G0475 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 G0476 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
235 G0480 Other Laboratory
235 G0481 Other Laboratory
235 G0482 Other Laboratory
235 G0483 Other Laboratory
236 G0490 Home Health Services
58 G0491 Hemodialysis
58 G0492 Hemodialysis
236 G0493 Home Health Services
236 G0494 Home Health Services
236 G0495 Home Health Services
236 G0496 Home Health Services
224 G0498 Cancer Chemotherapy
235 G0499 Other Laboratory
232 G0500 Anesthesia
227 G0501 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 G0506 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
M2C G0508 Hospital Visit - Critical Care
M2C G0509 Hospital Visit - Critical Care
227 G0511 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
218 G0512 Psychological And Psychiatric Evaluation And Therapy
M6 G0513 OP Consultations
M6 G0514 OP Consultations
Blue Cross NC Proprietary and Confidential 161 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
231 G0516 Other Therapeutic Procedures
174 G0517 Other Non-Or Therapeutic Procedures On Skin And Breast
231 G0518 Other Therapeutic Procedures
235 G0659 Other Laboratory
236 G2001 Home Health Services
236 G2002 Home Health Services
236 G2003 Home Health Services
236 G2004 Home Health Services
236 G2005 Home Health Services
236 G2006 Home Health Services
236 G2007 Home Health Services
236 G2008 Home Health Services
236 G2009 Home Health Services
236 G2010 Home Health Services
227 G2011 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
M1B G2012 Office Visits - Established
236 G2013 Home Health Services
236 G2014 Home Health Services
236 G2015 Home Health Services
40 G2023 Other Diagnostic Procedures Of Respiratory Tract And Mediastinum
40 G2024 Other Diagnostic Procedures Of Respiratory Tract And Mediastinum
M1B G2058 Office Visits - Established
M1B G2061 Office Visits - Established
M1B G2062 Office Visits - Established
M1B G2063 Office Visits - Established
M1B G2064 Office Visits - Established
M1B G2065 Office Visits - Established
62 G2066 Other Diagnostic Cardiovascular Procedures
219 G2067 Alcohol And Drug Rehabilitation/Detoxification
219 G2068 Alcohol And Drug Rehabilitation/Detoxification
219 G2069 Alcohol And Drug Rehabilitation/Detoxification
219 G2070 Alcohol And Drug Rehabilitation/Detoxification
219 G2071 Alcohol And Drug Rehabilitation/Detoxification
219 G2072 Alcohol And Drug Rehabilitation/Detoxification
219 G2073 Alcohol And Drug Rehabilitation/Detoxification
219 G2074 Alcohol And Drug Rehabilitation/Detoxification
219 G2075 Alcohol And Drug Rehabilitation/Detoxification
219 G2076 Alcohol And Drug Rehabilitation/Detoxification
219 G2077 Alcohol And Drug Rehabilitation/Detoxification
219 G2078 Alcohol And Drug Rehabilitation/Detoxification
219 G2079 Alcohol And Drug Rehabilitation/Detoxification
219 G2080 Alcohol And Drug Rehabilitation/Detoxification
219 G2082 Alcohol And Drug Rehabilitation/Detoxification
219 G2083 Alcohol And Drug Rehabilitation/Detoxification
219 G2086 Alcohol And Drug Rehabilitation/Detoxification
219 G2087 Alcohol And Drug Rehabilitation/Detoxification
219 G2088 Alcohol And Drug Rehabilitation/Detoxification
215 G2168 Other Physical Therapy And Rehabilitation
215 G2169 Other Physical Therapy And Rehabilitation
211 G6001 Therapeutic Radiology
211 G6002 Therapeutic Radiology
P7A G6003 Oncology - Radiation Therapy
P7A G6004 Oncology - Radiation Therapy
P7A G6005 Oncology - Radiation Therapy
P7A G6006 Oncology - Radiation Therapy
P7A G6007 Oncology - Radiation Therapy
P7A G6008 Oncology - Radiation Therapy
P7A G6009 Oncology - Radiation Therapy
P7A G6010 Oncology - Radiation Therapy
P7A G6011 Oncology - Radiation Therapy
P7A G6012 Oncology - Radiation Therapy
P7A G6013 Oncology - Radiation Therapy
P7A G6014 Oncology - Radiation Therapy
P7A G6015 Oncology - Radiation Therapy
P7A G6016 Oncology - Radiation Therapy
211 G6017 Therapeutic Radiology
235 G9143 Other Laboratory
227 G9156 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
203 G9157 Electrographic Cardiac Monitoring
227 G9187 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
237 G9473 Ancillary Services
237 G9474 Ancillary Services
237 G9475 Ancillary Services
237 G9476 Ancillary Services
Blue Cross NC Proprietary and Confidential 162 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
237 G9477 Ancillary Services
237 G9478 Ancillary Services
237 G9479 Ancillary Services
236 G9481 Home Health Services
236 G9482 Home Health Services
236 G9483 Home Health Services
236 G9484 Home Health Services
236 G9485 Home Health Services
236 G9486 Home Health Services
236 G9487 Home Health Services
236 G9488 Home Health Services
236 G9489 Home Health Services
236 G9490 Home Health Services
227 G9678 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 G9685 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
237 G9873 Ancillary Services
237 G9874 Ancillary Services
237 G9875 Ancillary Services
237 G9876 Ancillary Services
237 G9877 Ancillary Services
237 G9878 Ancillary Services
237 G9879 Ancillary Services
237 G9880 Ancillary Services
237 G9881 Ancillary Services
237 G9882 Ancillary Services
237 G9883 Ancillary Services
237 G9884 Ancillary Services
237 G9885 Ancillary Services
237 G9890 Ancillary Services
219 H0001 Alcohol And Drug Rehabilitation/Detoxification
219 H0002 Alcohol And Drug Rehabilitation/Detoxification
219 H0003 Alcohol And Drug Rehabilitation/Detoxification
219 H0004 Alcohol And Drug Rehabilitation/Detoxification
219 H0005 Alcohol And Drug Rehabilitation/Detoxification
219 H0006 Alcohol And Drug Rehabilitation/Detoxification
219 H0007 Alcohol And Drug Rehabilitation/Detoxification
219 H0008 Alcohol And Drug Rehabilitation/Detoxification
219 H0009 Alcohol And Drug Rehabilitation/Detoxification
219 H0010 Alcohol And Drug Rehabilitation/Detoxification
219 H0011 Alcohol And Drug Rehabilitation/Detoxification
219 H0012 Alcohol And Drug Rehabilitation/Detoxification
219 H0013 Alcohol And Drug Rehabilitation/Detoxification
219 H0014 Alcohol And Drug Rehabilitation/Detoxification
219 H0015 Alcohol And Drug Rehabilitation/Detoxification
219 H0016 Alcohol And Drug Rehabilitation/Detoxification
219 H0017 Alcohol And Drug Rehabilitation/Detoxification
219 H0018 Alcohol And Drug Rehabilitation/Detoxification
219 H0019 Alcohol And Drug Rehabilitation/Detoxification
219 H0020 Alcohol And Drug Rehabilitation/Detoxification
219 H0021 Alcohol And Drug Rehabilitation/Detoxification
219 H0022 Alcohol And Drug Rehabilitation/Detoxification
219 H0023 Alcohol And Drug Rehabilitation/Detoxification
219 H0024 Alcohol And Drug Rehabilitation/Detoxification
219 H0025 Alcohol And Drug Rehabilitation/Detoxification
219 H0026 Alcohol And Drug Rehabilitation/Detoxification
219 H0027 Alcohol And Drug Rehabilitation/Detoxification
219 H0028 Alcohol And Drug Rehabilitation/Detoxification
219 H0029 Alcohol And Drug Rehabilitation/Detoxification
219 H0030 Alcohol And Drug Rehabilitation/Detoxification
218 H0031 Psychological And Psychiatric Evaluation And Therapy
218 H0032 Psychological And Psychiatric Evaluation And Therapy
219 H0033 Alcohol And Drug Rehabilitation/Detoxification
227 H0034 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
218 H0035 Psychological And Psychiatric Evaluation And Therapy
218 H0036 Psychological And Psychiatric Evaluation And Therapy
218 H0037 Psychological And Psychiatric Evaluation And Therapy
219 H0038 Alcohol And Drug Rehabilitation/Detoxification
219 H0039 Alcohol And Drug Rehabilitation/Detoxification
219 H0040 Alcohol And Drug Rehabilitation/Detoxification
237 H0041 Ancillary Services
237 H0042 Ancillary Services
237 H0043 Ancillary Services
237 H0044 Ancillary Services
227 H0045 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
Blue Cross NC Proprietary and Confidential 163 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
218 H0046 Psychological And Psychiatric Evaluation And Therapy
219 H0047 Alcohol And Drug Rehabilitation/Detoxification
219 H0048 Alcohol And Drug Rehabilitation/Detoxification
219 H0049 Alcohol And Drug Rehabilitation/Detoxification
219 H0050 Alcohol And Drug Rehabilitation/Detoxification
227 H1000 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 H1001 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 H1002 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 H1003 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 H1004 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 H1005 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 H1010 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 H1011 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 H2000 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
219 H2001 Alcohol And Drug Rehabilitation/Detoxification
227 H2010 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
219 H2011 Alcohol And Drug Rehabilitation/Detoxification
219 H2012 Alcohol And Drug Rehabilitation/Detoxification
218 H2013 Psychological And Psychiatric Evaluation And Therapy
219 H2014 Alcohol And Drug Rehabilitation/Detoxification
219 H2015 Alcohol And Drug Rehabilitation/Detoxification
219 H2016 Alcohol And Drug Rehabilitation/Detoxification
218 H2017 Psychological And Psychiatric Evaluation And Therapy
218 H2018 Psychological And Psychiatric Evaluation And Therapy
219 H2019 Alcohol And Drug Rehabilitation/Detoxification
219 H2020 Alcohol And Drug Rehabilitation/Detoxification
237 H2021 Ancillary Services
237 H2022 Ancillary Services
237 H2023 Ancillary Services
237 H2024 Ancillary Services
219 H2025 Alcohol And Drug Rehabilitation/Detoxification
219 H2026 Alcohol And Drug Rehabilitation/Detoxification
218 H2027 Psychological And Psychiatric Evaluation And Therapy
218 H2028 Psychological And Psychiatric Evaluation And Therapy
218 H2029 Psychological And Psychiatric Evaluation And Therapy
218 H2030 Psychological And Psychiatric Evaluation And Therapy
218 H2031 Psychological And Psychiatric Evaluation And Therapy
218 H2032 Psychological And Psychiatric Evaluation And Therapy
218 H2033 Psychological And Psychiatric Evaluation And Therapy
219 H2034 Alcohol And Drug Rehabilitation/Detoxification
219 H2035 Alcohol And Drug Rehabilitation/Detoxification
219 H2036 Alcohol And Drug Rehabilitation/Detoxification
218 H2037 Psychological And Psychiatric Evaluation And Therapy
240 J0120 Medications (Injections, infusions and other forms)
240 J0121 Medications (Injections, infusions and other forms)
240 J0122 Medications (Injections, infusions and other forms)
240 J0129 Medications (Injections, infusions and other forms)
240 J0130 Medications (Injections, infusions and other forms)
240 J0131 Medications (Injections, infusions and other forms)
240 J0132 Medications (Injections, infusions and other forms)
240 J0133 Medications (Injections, infusions and other forms)
240 J0135 Medications (Injections, infusions and other forms)
240 J0153 Medications (Injections, infusions and other forms)
240 J0171 Medications (Injections, infusions and other forms)
240 J0178 Medications (Injections, infusions and other forms)
240 J0179 Medications (Injections, infusions and other forms)
240 J0180 Medications (Injections, infusions and other forms)
240 J0185 Medications (Injections, infusions and other forms)
240 J0190 Medications (Injections, infusions and other forms)
240 J0200 Medications (Injections, infusions and other forms)
240 J0202 Medications (Injections, infusions and other forms)
240 J0205 Medications (Injections, infusions and other forms)
240 J0207 Medications (Injections, infusions and other forms)
240 J0210 Medications (Injections, infusions and other forms)
240 J0215 Medications (Injections, infusions and other forms)
240 J0220 Medications (Injections, infusions and other forms)
240 J0221 Medications (Injections, infusions and other forms)
240 J0222 Medications (Injections, infusions and other forms)
240 J0256 Medications (Injections, infusions and other forms)
240 J0257 Medications (Injections, infusions and other forms)
240 J0270 Medications (Injections, infusions and other forms)
240 J0275 Medications (Injections, infusions and other forms)
240 J0278 Medications (Injections, infusions and other forms)
240 J0280 Medications (Injections, infusions and other forms)
Blue Cross NC Proprietary and Confidential 164 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
240 J0282 Medications (Injections, infusions and other forms)
240 J0285 Medications (Injections, infusions and other forms)
240 J0287 Medications (Injections, infusions and other forms)
240 J0288 Medications (Injections, infusions and other forms)
240 J0289 Medications (Injections, infusions and other forms)
240 J0290 Medications (Injections, infusions and other forms)
240 J0291 Medications (Injections, infusions and other forms)
240 J0295 Medications (Injections, infusions and other forms)
240 J0300 Medications (Injections, infusions and other forms)
240 J0330 Medications (Injections, infusions and other forms)
240 J0348 Medications (Injections, infusions and other forms)
240 J0350 Medications (Injections, infusions and other forms)
240 J0360 Medications (Injections, infusions and other forms)
240 J0364 Medications (Injections, infusions and other forms)
240 J0365 Medications (Injections, infusions and other forms)
240 J0380 Medications (Injections, infusions and other forms)
240 J0390 Medications (Injections, infusions and other forms)
240 J0395 Medications (Injections, infusions and other forms)
240 J0400 Medications (Injections, infusions and other forms)
240 J0401 Medications (Injections, infusions and other forms)
240 J0456 Medications (Injections, infusions and other forms)
240 J0461 Medications (Injections, infusions and other forms)
240 J0470 Medications (Injections, infusions and other forms)
240 J0475 Medications (Injections, infusions and other forms)
240 J0476 Medications (Injections, infusions and other forms)
240 J0480 Medications (Injections, infusions and other forms)
240 J0485 Medications (Injections, infusions and other forms)
240 J0490 Medications (Injections, infusions and other forms)
240 J0500 Medications (Injections, infusions and other forms)
240 J0515 Medications (Injections, infusions and other forms)
240 J0517 Medications (Injections, infusions and other forms)
240 J0520 Medications (Injections, infusions and other forms)
240 J0558 Medications (Injections, infusions and other forms)
240 J0561 Medications (Injections, infusions and other forms)
240 J0565 Medications (Injections, infusions and other forms)
240 J0567 Medications (Injections, infusions and other forms)
240 J0570 Medications (Injections, infusions and other forms)
240 J0571 Medications (Injections, infusions and other forms)
240 J0572 Medications (Injections, infusions and other forms)
240 J0573 Medications (Injections, infusions and other forms)
240 J0574 Medications (Injections, infusions and other forms)
240 J0575 Medications (Injections, infusions and other forms)
240 J0583 Medications (Injections, infusions and other forms)
240 J0584 Medications (Injections, infusions and other forms)
240 J0585 Medications (Injections, infusions and other forms)
240 J0586 Medications (Injections, infusions and other forms)
240 J0587 Medications (Injections, infusions and other forms)
240 J0588 Medications (Injections, infusions and other forms)
240 J0592 Medications (Injections, infusions and other forms)
240 J0593 Medications (Injections, infusions and other forms)
240 J0594 Medications (Injections, infusions and other forms)
240 J0595 Medications (Injections, infusions and other forms)
240 J0596 Medications (Injections, infusions and other forms)
240 J0597 Medications (Injections, infusions and other forms)
240 J0598 Medications (Injections, infusions and other forms)
240 J0599 Medications (Injections, infusions and other forms)
240 J0600 Medications (Injections, infusions and other forms)
240 J0604 Medications (Injections, infusions and other forms)
240 J0606 Medications (Injections, infusions and other forms)
240 J0610 Medications (Injections, infusions and other forms)
240 J0620 Medications (Injections, infusions and other forms)
240 J0630 Medications (Injections, infusions and other forms)
240 J0636 Medications (Injections, infusions and other forms)
240 J0637 Medications (Injections, infusions and other forms)
240 J0638 Medications (Injections, infusions and other forms)
240 J0640 Medications (Injections, infusions and other forms)
240 J0641 Medications (Injections, infusions and other forms)
240 J0642 Medications (Injections, infusions and other forms)
240 J0670 Medications (Injections, infusions and other forms)
240 J0690 Medications (Injections, infusions and other forms)
240 J0692 Medications (Injections, infusions and other forms)
240 J0694 Medications (Injections, infusions and other forms)
240 J0695 Medications (Injections, infusions and other forms)
240 J0696 Medications (Injections, infusions and other forms)
Blue Cross NC Proprietary and Confidential 165 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
240 J0697 Medications (Injections, infusions and other forms)
240 J0698 Medications (Injections, infusions and other forms)
240 J0702 Medications (Injections, infusions and other forms)
240 J0706 Medications (Injections, infusions and other forms)
240 J0710 Medications (Injections, infusions and other forms)
240 J0712 Medications (Injections, infusions and other forms)
240 J0713 Medications (Injections, infusions and other forms)
240 J0714 Medications (Injections, infusions and other forms)
240 J0715 Medications (Injections, infusions and other forms)
240 J0716 Medications (Injections, infusions and other forms)
240 J0717 Medications (Injections, infusions and other forms)
240 J0720 Medications (Injections, infusions and other forms)
240 J0725 Medications (Injections, infusions and other forms)
240 J0735 Medications (Injections, infusions and other forms)
240 J0740 Medications (Injections, infusions and other forms)
240 J0743 Medications (Injections, infusions and other forms)
240 J0744 Medications (Injections, infusions and other forms)
240 J0745 Medications (Injections, infusions and other forms)
240 J0770 Medications (Injections, infusions and other forms)
240 J0775 Medications (Injections, infusions and other forms)
240 J0780 Medications (Injections, infusions and other forms)
240 J0795 Medications (Injections, infusions and other forms)
240 J0800 Medications (Injections, infusions and other forms)
240 J0834 Medications (Injections, infusions and other forms)
240 J0840 Medications (Injections, infusions and other forms)
240 J0841 Medications (Injections, infusions and other forms)
240 J0850 Medications (Injections, infusions and other forms)
240 J0875 Medications (Injections, infusions and other forms)
240 J0878 Medications (Injections, infusions and other forms)
240 J0881 Medications (Injections, infusions and other forms)
240 J0882 Medications (Injections, infusions and other forms)
240 J0883 Medications (Injections, infusions and other forms)
240 J0884 Medications (Injections, infusions and other forms)
240 J0885 Medications (Injections, infusions and other forms)
240 J0887 Medications (Injections, infusions and other forms)
240 J0888 Medications (Injections, infusions and other forms)
240 J0890 Medications (Injections, infusions and other forms)
240 J0894 Medications (Injections, infusions and other forms)
240 J0895 Medications (Injections, infusions and other forms)
240 J0897 Medications (Injections, infusions and other forms)
240 J0945 Medications (Injections, infusions and other forms)
240 J1000 Medications (Injections, infusions and other forms)
240 J1020 Medications (Injections, infusions and other forms)
240 J1030 Medications (Injections, infusions and other forms)
240 J1040 Medications (Injections, infusions and other forms)
240 J1050 Medications (Injections, infusions and other forms)
240 J1071 Medications (Injections, infusions and other forms)
240 J1094 Medications (Injections, infusions and other forms)
240 J1095 Medications (Injections, infusions and other forms)
240 J1096 Medications (Injections, infusions and other forms)
240 J1097 Medications (Injections, infusions and other forms)
240 J1100 Medications (Injections, infusions and other forms)
240 J1110 Medications (Injections, infusions and other forms)
240 J1120 Medications (Injections, infusions and other forms)
240 J1130 Medications (Injections, infusions and other forms)
240 J1160 Medications (Injections, infusions and other forms)
240 J1162 Medications (Injections, infusions and other forms)
240 J1165 Medications (Injections, infusions and other forms)
240 J1170 Medications (Injections, infusions and other forms)
240 J1180 Medications (Injections, infusions and other forms)
240 J1190 Medications (Injections, infusions and other forms)
240 J1200 Medications (Injections, infusions and other forms)
240 J1205 Medications (Injections, infusions and other forms)
240 J1212 Medications (Injections, infusions and other forms)
240 J1230 Medications (Injections, infusions and other forms)
240 J1240 Medications (Injections, infusions and other forms)
240 J1245 Medications (Injections, infusions and other forms)
240 J1250 Medications (Injections, infusions and other forms)
240 J1260 Medications (Injections, infusions and other forms)
240 J1265 Medications (Injections, infusions and other forms)
240 J1267 Medications (Injections, infusions and other forms)
240 J1270 Medications (Injections, infusions and other forms)
240 J1290 Medications (Injections, infusions and other forms)
240 J1300 Medications (Injections, infusions and other forms)
Blue Cross NC Proprietary and Confidential 166 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
240 J1301 Medications (Injections, infusions and other forms)
240 J1303 Medications (Injections, infusions and other forms)
240 J1320 Medications (Injections, infusions and other forms)
240 J1322 Medications (Injections, infusions and other forms)
240 J1324 Medications (Injections, infusions and other forms)
240 J1325 Medications (Injections, infusions and other forms)
240 J1327 Medications (Injections, infusions and other forms)
240 J1330 Medications (Injections, infusions and other forms)
240 J1335 Medications (Injections, infusions and other forms)
240 J1364 Medications (Injections, infusions and other forms)
240 J1380 Medications (Injections, infusions and other forms)
240 J1410 Medications (Injections, infusions and other forms)
240 J1428 Medications (Injections, infusions and other forms)
240 J1430 Medications (Injections, infusions and other forms)
240 J1435 Medications (Injections, infusions and other forms)
240 J1436 Medications (Injections, infusions and other forms)
240 J1438 Medications (Injections, infusions and other forms)
240 J1439 Medications (Injections, infusions and other forms)
240 J1442 Medications (Injections, infusions and other forms)
240 J1443 Medications (Injections, infusions and other forms)
240 J1444 Medications (Injections, infusions and other forms)
240 J1447 Medications (Injections, infusions and other forms)
240 J1450 Medications (Injections, infusions and other forms)
240 J1451 Medications (Injections, infusions and other forms)
240 J1452 Medications (Injections, infusions and other forms)
240 J1453 Medications (Injections, infusions and other forms)
240 J1454 Medications (Injections, infusions and other forms)
240 J1455 Medications (Injections, infusions and other forms)
240 J1457 Medications (Injections, infusions and other forms)
240 J1458 Medications (Injections, infusions and other forms)
240 J1459 Medications (Injections, infusions and other forms)
240 J1460 Medications (Injections, infusions and other forms)
240 J1555 Medications (Injections, infusions and other forms)
240 J1556 Medications (Injections, infusions and other forms)
240 J1557 Medications (Injections, infusions and other forms)
240 J1559 Medications (Injections, infusions and other forms)
240 J1560 Medications (Injections, infusions and other forms)
240 J1561 Medications (Injections, infusions and other forms)
240 J1562 Medications (Injections, infusions and other forms)
240 J1566 Medications (Injections, infusions and other forms)
240 J1568 Medications (Injections, infusions and other forms)
240 J1569 Medications (Injections, infusions and other forms)
240 J1570 Medications (Injections, infusions and other forms)
240 J1571 Medications (Injections, infusions and other forms)
240 J1572 Medications (Injections, infusions and other forms)
240 J1573 Medications (Injections, infusions and other forms)
240 J1575 Medications (Injections, infusions and other forms)
240 J1580 Medications (Injections, infusions and other forms)
240 J1595 Medications (Injections, infusions and other forms)
240 J1599 Medications (Injections, infusions and other forms)
240 J1600 Medications (Injections, infusions and other forms)
240 J1602 Medications (Injections, infusions and other forms)
240 J1610 Medications (Injections, infusions and other forms)
240 J1620 Medications (Injections, infusions and other forms)
240 J1626 Medications (Injections, infusions and other forms)
240 J1627 Medications (Injections, infusions and other forms)
240 J1628 Medications (Injections, infusions and other forms)
240 J1630 Medications (Injections, infusions and other forms)
240 J1631 Medications (Injections, infusions and other forms)
240 J1640 Medications (Injections, infusions and other forms)
240 J1642 Medications (Injections, infusions and other forms)
240 J1644 Medications (Injections, infusions and other forms)
240 J1645 Medications (Injections, infusions and other forms)
240 J1650 Medications (Injections, infusions and other forms)
240 J1652 Medications (Injections, infusions and other forms)
240 J1655 Medications (Injections, infusions and other forms)
240 J1670 Medications (Injections, infusions and other forms)
240 J1675 Medications (Injections, infusions and other forms)
240 J1700 Medications (Injections, infusions and other forms)
240 J1710 Medications (Injections, infusions and other forms)
240 J1720 Medications (Injections, infusions and other forms)
240 J1726 Medications (Injections, infusions and other forms)
240 J1729 Medications (Injections, infusions and other forms)
240 J1730 Medications (Injections, infusions and other forms)
Blue Cross NC Proprietary and Confidential 167 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
240 J1740 Medications (Injections, infusions and other forms)
240 J1741 Medications (Injections, infusions and other forms)
240 J1742 Medications (Injections, infusions and other forms)
240 J1743 Medications (Injections, infusions and other forms)
240 J1744 Medications (Injections, infusions and other forms)
240 J1745 Medications (Injections, infusions and other forms)
240 J1746 Medications (Injections, infusions and other forms)
240 J1750 Medications (Injections, infusions and other forms)
240 J1756 Medications (Injections, infusions and other forms)
240 J1786 Medications (Injections, infusions and other forms)
240 J1790 Medications (Injections, infusions and other forms)
240 J1800 Medications (Injections, infusions and other forms)
240 J1810 Medications (Injections, infusions and other forms)
240 J1815 Medications (Injections, infusions and other forms)
240 J1817 Medications (Injections, infusions and other forms)
240 J1826 Medications (Injections, infusions and other forms)
240 J1830 Medications (Injections, infusions and other forms)
240 J1833 Medications (Injections, infusions and other forms)
240 J1835 Medications (Injections, infusions and other forms)
240 J1840 Medications (Injections, infusions and other forms)
240 J1850 Medications (Injections, infusions and other forms)
240 J1885 Medications (Injections, infusions and other forms)
240 J1890 Medications (Injections, infusions and other forms)
240 J1930 Medications (Injections, infusions and other forms)
240 J1931 Medications (Injections, infusions and other forms)
240 J1940 Medications (Injections, infusions and other forms)
240 J1943 Medications (Injections, infusions and other forms)
240 J1944 Medications (Injections, infusions and other forms)
240 J1945 Medications (Injections, infusions and other forms)
240 J1950 Medications (Injections, infusions and other forms)
240 J1953 Medications (Injections, infusions and other forms)
240 J1955 Medications (Injections, infusions and other forms)
240 J1956 Medications (Injections, infusions and other forms)
240 J1960 Medications (Injections, infusions and other forms)
240 J1980 Medications (Injections, infusions and other forms)
240 J1990 Medications (Injections, infusions and other forms)
240 J2001 Medications (Injections, infusions and other forms)
240 J2010 Medications (Injections, infusions and other forms)
240 J2020 Medications (Injections, infusions and other forms)
240 J2060 Medications (Injections, infusions and other forms)
240 J2062 Medications (Injections, infusions and other forms)
240 J2150 Medications (Injections, infusions and other forms)
240 J2170 Medications (Injections, infusions and other forms)
240 J2175 Medications (Injections, infusions and other forms)
240 J2180 Medications (Injections, infusions and other forms)
240 J2182 Medications (Injections, infusions and other forms)
240 J2185 Medications (Injections, infusions and other forms)
240 J2186 Medications (Injections, infusions and other forms)
240 J2210 Medications (Injections, infusions and other forms)
240 J2212 Medications (Injections, infusions and other forms)
240 J2248 Medications (Injections, infusions and other forms)
240 J2250 Medications (Injections, infusions and other forms)
240 J2260 Medications (Injections, infusions and other forms)
240 J2265 Medications (Injections, infusions and other forms)
240 J2270 Medications (Injections, infusions and other forms)
240 J2274 Medications (Injections, infusions and other forms)
240 J2278 Medications (Injections, infusions and other forms)
240 J2280 Medications (Injections, infusions and other forms)
240 J2300 Medications (Injections, infusions and other forms)
240 J2310 Medications (Injections, infusions and other forms)
240 J2315 Medications (Injections, infusions and other forms)
240 J2320 Medications (Injections, infusions and other forms)
240 J2323 Medications (Injections, infusions and other forms)
240 J2325 Medications (Injections, infusions and other forms)
240 J2326 Medications (Injections, infusions and other forms)
240 J2350 Medications (Injections, infusions and other forms)
240 J2353 Medications (Injections, infusions and other forms)
240 J2354 Medications (Injections, infusions and other forms)
240 J2355 Medications (Injections, infusions and other forms)
240 J2357 Medications (Injections, infusions and other forms)
240 J2358 Medications (Injections, infusions and other forms)
240 J2360 Medications (Injections, infusions and other forms)
240 J2370 Medications (Injections, infusions and other forms)
240 J2400 Medications (Injections, infusions and other forms)
Blue Cross NC Proprietary and Confidential 168 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
240 J2405 Medications (Injections, infusions and other forms)
240 J2407 Medications (Injections, infusions and other forms)
240 J2410 Medications (Injections, infusions and other forms)
240 J2425 Medications (Injections, infusions and other forms)
240 J2426 Medications (Injections, infusions and other forms)
240 J2430 Medications (Injections, infusions and other forms)
240 J2440 Medications (Injections, infusions and other forms)
240 J2460 Medications (Injections, infusions and other forms)
240 J2469 Medications (Injections, infusions and other forms)
240 J2501 Medications (Injections, infusions and other forms)
240 J2502 Medications (Injections, infusions and other forms)
240 J2503 Medications (Injections, infusions and other forms)
240 J2504 Medications (Injections, infusions and other forms)
240 J2505 Medications (Injections, infusions and other forms)
240 J2507 Medications (Injections, infusions and other forms)
240 J2510 Medications (Injections, infusions and other forms)
240 J2513 Medications (Injections, infusions and other forms)
240 J2515 Medications (Injections, infusions and other forms)
240 J2540 Medications (Injections, infusions and other forms)
240 J2543 Medications (Injections, infusions and other forms)
240 J2545 Medications (Injections, infusions and other forms)
240 J2547 Medications (Injections, infusions and other forms)
240 J2550 Medications (Injections, infusions and other forms)
240 J2560 Medications (Injections, infusions and other forms)
240 J2562 Medications (Injections, infusions and other forms)
240 J2590 Medications (Injections, infusions and other forms)
240 J2597 Medications (Injections, infusions and other forms)
240 J2650 Medications (Injections, infusions and other forms)
240 J2670 Medications (Injections, infusions and other forms)
240 J2675 Medications (Injections, infusions and other forms)
240 J2680 Medications (Injections, infusions and other forms)
240 J2690 Medications (Injections, infusions and other forms)
240 J2700 Medications (Injections, infusions and other forms)
240 J2704 Medications (Injections, infusions and other forms)
240 J2710 Medications (Injections, infusions and other forms)
240 J2720 Medications (Injections, infusions and other forms)
240 J2724 Medications (Injections, infusions and other forms)
240 J2725 Medications (Injections, infusions and other forms)
240 J2730 Medications (Injections, infusions and other forms)
240 J2760 Medications (Injections, infusions and other forms)
240 J2765 Medications (Injections, infusions and other forms)
240 J2770 Medications (Injections, infusions and other forms)
240 J2778 Medications (Injections, infusions and other forms)
240 J2780 Medications (Injections, infusions and other forms)
240 J2783 Medications (Injections, infusions and other forms)
240 J2785 Medications (Injections, infusions and other forms)
240 J2786 Medications (Injections, infusions and other forms)
240 J2787 Medications (Injections, infusions and other forms)
240 J2788 Medications (Injections, infusions and other forms)
240 J2790 Medications (Injections, infusions and other forms)
240 J2791 Medications (Injections, infusions and other forms)
240 J2792 Medications (Injections, infusions and other forms)
240 J2793 Medications (Injections, infusions and other forms)
240 J2794 Medications (Injections, infusions and other forms)
240 J2795 Medications (Injections, infusions and other forms)
240 J2796 Medications (Injections, infusions and other forms)
240 J2797 Medications (Injections, infusions and other forms)
240 J2798 Medications (Injections, infusions and other forms)
240 J2800 Medications (Injections, infusions and other forms)
240 J2805 Medications (Injections, infusions and other forms)
240 J2810 Medications (Injections, infusions and other forms)
240 J2820 Medications (Injections, infusions and other forms)
240 J2840 Medications (Injections, infusions and other forms)
240 J2850 Medications (Injections, infusions and other forms)
240 J2860 Medications (Injections, infusions and other forms)
240 J2910 Medications (Injections, infusions and other forms)
240 J2916 Medications (Injections, infusions and other forms)
240 J2920 Medications (Injections, infusions and other forms)
240 J2930 Medications (Injections, infusions and other forms)
240 J2940 Medications (Injections, infusions and other forms)
240 J2941 Medications (Injections, infusions and other forms)
240 J2950 Medications (Injections, infusions and other forms)
240 J2993 Medications (Injections, infusions and other forms)
240 J2995 Medications (Injections, infusions and other forms)
Blue Cross NC Proprietary and Confidential 169 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
240 J2997 Medications (Injections, infusions and other forms)
240 J3000 Medications (Injections, infusions and other forms)
240 J3010 Medications (Injections, infusions and other forms)
240 J3030 Medications (Injections, infusions and other forms)
240 J3031 Medications (Injections, infusions and other forms)
240 J3060 Medications (Injections, infusions and other forms)
240 J3070 Medications (Injections, infusions and other forms)
240 J3090 Medications (Injections, infusions and other forms)
240 J3095 Medications (Injections, infusions and other forms)
240 J3101 Medications (Injections, infusions and other forms)
240 J3105 Medications (Injections, infusions and other forms)
240 J3110 Medications (Injections, infusions and other forms)
240 J3111 Medications (Injections, infusions and other forms)
240 J3121 Medications (Injections, infusions and other forms)
240 J3145 Medications (Injections, infusions and other forms)
240 J3230 Medications (Injections, infusions and other forms)
240 J3240 Medications (Injections, infusions and other forms)
240 J3243 Medications (Injections, infusions and other forms)
240 J3245 Medications (Injections, infusions and other forms)
240 J3246 Medications (Injections, infusions and other forms)
240 J3250 Medications (Injections, infusions and other forms)
240 J3260 Medications (Injections, infusions and other forms)
240 J3262 Medications (Injections, infusions and other forms)
240 J3265 Medications (Injections, infusions and other forms)
240 J3280 Medications (Injections, infusions and other forms)
240 J3285 Medications (Injections, infusions and other forms)
240 J3300 Medications (Injections, infusions and other forms)
240 J3301 Medications (Injections, infusions and other forms)
240 J3302 Medications (Injections, infusions and other forms)
240 J3303 Medications (Injections, infusions and other forms)
240 J3304 Medications (Injections, infusions and other forms)
240 J3305 Medications (Injections, infusions and other forms)
240 J3310 Medications (Injections, infusions and other forms)
240 J3315 Medications (Injections, infusions and other forms)
240 J3316 Medications (Injections, infusions and other forms)
240 J3320 Medications (Injections, infusions and other forms)
240 J3350 Medications (Injections, infusions and other forms)
240 J3355 Medications (Injections, infusions and other forms)
240 J3357 Medications (Injections, infusions and other forms)
240 J3358 Medications (Injections, infusions and other forms)
240 J3360 Medications (Injections, infusions and other forms)
240 J3364 Medications (Injections, infusions and other forms)
240 J3365 Medications (Injections, infusions and other forms)
240 J3370 Medications (Injections, infusions and other forms)
240 J3380 Medications (Injections, infusions and other forms)
240 J3385 Medications (Injections, infusions and other forms)
240 J3396 Medications (Injections, infusions and other forms)
240 J3397 Medications (Injections, infusions and other forms)
240 J3398 Medications (Injections, infusions and other forms)
240 J3400 Medications (Injections, infusions and other forms)
240 J3410 Medications (Injections, infusions and other forms)
240 J3411 Medications (Injections, infusions and other forms)
240 J3415 Medications (Injections, infusions and other forms)
240 J3420 Medications (Injections, infusions and other forms)
240 J3430 Medications (Injections, infusions and other forms)
240 J3465 Medications (Injections, infusions and other forms)
240 J3470 Medications (Injections, infusions and other forms)
240 J3471 Medications (Injections, infusions and other forms)
240 J3472 Medications (Injections, infusions and other forms)
240 J3473 Medications (Injections, infusions and other forms)
240 J3475 Medications (Injections, infusions and other forms)
240 J3480 Medications (Injections, infusions and other forms)
240 J3485 Medications (Injections, infusions and other forms)
240 J3486 Medications (Injections, infusions and other forms)
240 J3489 Medications (Injections, infusions and other forms)
240 J3490 Medications (Injections, infusions and other forms)
240 J3520 Medications (Injections, infusions and other forms)
240 J3530 Medications (Injections, infusions and other forms)
240 J3535 Medications (Injections, infusions and other forms)
240 J3570 Medications (Injections, infusions and other forms)
240 J3590 Medications (Injections, infusions and other forms)
240 J3591 Medications (Injections, infusions and other forms)
240 J7030 Medications (Injections, infusions and other forms)
240 J7040 Medications (Injections, infusions and other forms)
Blue Cross NC Proprietary and Confidential 170 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
240 J7042 Medications (Injections, infusions and other forms)
240 J7050 Medications (Injections, infusions and other forms)
240 J7060 Medications (Injections, infusions and other forms)
240 J7070 Medications (Injections, infusions and other forms)
240 J7100 Medications (Injections, infusions and other forms)
240 J7110 Medications (Injections, infusions and other forms)
240 J7120 Medications (Injections, infusions and other forms)
240 J7121 Medications (Injections, infusions and other forms)
240 J7131 Medications (Injections, infusions and other forms)
240 J7170 Medications (Injections, infusions and other forms)
240 J7175 Medications (Injections, infusions and other forms)
240 J7177 Medications (Injections, infusions and other forms)
240 J7178 Medications (Injections, infusions and other forms)
240 J7179 Medications (Injections, infusions and other forms)
240 J7180 Medications (Injections, infusions and other forms)
240 J7181 Medications (Injections, infusions and other forms)
240 J7182 Medications (Injections, infusions and other forms)
240 J7183 Medications (Injections, infusions and other forms)
240 J7185 Medications (Injections, infusions and other forms)
240 J7186 Medications (Injections, infusions and other forms)
240 J7187 Medications (Injections, infusions and other forms)
240 J7188 Medications (Injections, infusions and other forms)
240 J7189 Medications (Injections, infusions and other forms)
240 J7190 Medications (Injections, infusions and other forms)
240 J7191 Medications (Injections, infusions and other forms)
240 J7192 Medications (Injections, infusions and other forms)
240 J7193 Medications (Injections, infusions and other forms)
240 J7194 Medications (Injections, infusions and other forms)
240 J7195 Medications (Injections, infusions and other forms)
240 J7196 Medications (Injections, infusions and other forms)
240 J7197 Medications (Injections, infusions and other forms)
240 J7198 Medications (Injections, infusions and other forms)
240 J7199 Medications (Injections, infusions and other forms)
240 J7200 Medications (Injections, infusions and other forms)
240 J7201 Medications (Injections, infusions and other forms)
240 J7202 Medications (Injections, infusions and other forms)
240 J7203 Medications (Injections, infusions and other forms)
240 J7205 Medications (Injections, infusions and other forms)
240 J7207 Medications (Injections, infusions and other forms)
240 J7208 Medications (Injections, infusions and other forms)
240 J7209 Medications (Injections, infusions and other forms)
240 J7210 Medications (Injections, infusions and other forms)
240 J7211 Medications (Injections, infusions and other forms)
240 J7296 Medications (Injections, infusions and other forms)
240 J7297 Medications (Injections, infusions and other forms)
240 J7298 Medications (Injections, infusions and other forms)
240 J7300 Medications (Injections, infusions and other forms)
240 J7301 Medications (Injections, infusions and other forms)
240 J7303 Medications (Injections, infusions and other forms)
240 J7304 Medications (Injections, infusions and other forms)
240 J7306 Medications (Injections, infusions and other forms)
240 J7307 Medications (Injections, infusions and other forms)
240 J7308 Medications (Injections, infusions and other forms)
240 J7309 Medications (Injections, infusions and other forms)
240 J7310 Medications (Injections, infusions and other forms)
240 J7311 Medications (Injections, infusions and other forms)
240 J7312 Medications (Injections, infusions and other forms)
240 J7313 Medications (Injections, infusions and other forms)
240 J7314 Medications (Injections, infusions and other forms)
240 J7315 Medications (Injections, infusions and other forms)
240 J7316 Medications (Injections, infusions and other forms)
240 J7318 Medications (Injections, infusions and other forms)
240 J7320 Medications (Injections, infusions and other forms)
240 J7321 Medications (Injections, infusions and other forms)
240 J7322 Medications (Injections, infusions and other forms)
240 J7323 Medications (Injections, infusions and other forms)
240 J7324 Medications (Injections, infusions and other forms)
240 J7325 Medications (Injections, infusions and other forms)
240 J7326 Medications (Injections, infusions and other forms)
240 J7327 Medications (Injections, infusions and other forms)
240 J7328 Medications (Injections, infusions and other forms)
240 J7329 Medications (Injections, infusions and other forms)
240 J7330 Medications (Injections, infusions and other forms)
240 J7331 Medications (Injections, infusions and other forms)
Blue Cross NC Proprietary and Confidential 171 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
240 J7332 Medications (Injections, infusions and other forms)
240 J7336 Medications (Injections, infusions and other forms)
240 J7340 Medications (Injections, infusions and other forms)
240 J7342 Medications (Injections, infusions and other forms)
240 J7345 Medications (Injections, infusions and other forms)
240 J7401 Medications (Injections, infusions and other forms)
240 J7500 Medications (Injections, infusions and other forms)
240 J7501 Medications (Injections, infusions and other forms)
240 J7502 Medications (Injections, infusions and other forms)
240 J7503 Medications (Injections, infusions and other forms)
240 J7504 Medications (Injections, infusions and other forms)
240 J7505 Medications (Injections, infusions and other forms)
240 J7507 Medications (Injections, infusions and other forms)
240 J7508 Medications (Injections, infusions and other forms)
240 J7509 Medications (Injections, infusions and other forms)
240 J7510 Medications (Injections, infusions and other forms)
240 J7511 Medications (Injections, infusions and other forms)
240 J7512 Medications (Injections, infusions and other forms)
240 J7513 Medications (Injections, infusions and other forms)
240 J7515 Medications (Injections, infusions and other forms)
240 J7516 Medications (Injections, infusions and other forms)
240 J7517 Medications (Injections, infusions and other forms)
240 J7518 Medications (Injections, infusions and other forms)
240 J7520 Medications (Injections, infusions and other forms)
240 J7525 Medications (Injections, infusions and other forms)
240 J7527 Medications (Injections, infusions and other forms)
240 J7599 Medications (Injections, infusions and other forms)
240 J7604 Medications (Injections, infusions and other forms)
240 J7605 Medications (Injections, infusions and other forms)
240 J7606 Medications (Injections, infusions and other forms)
240 J7607 Medications (Injections, infusions and other forms)
240 J7608 Medications (Injections, infusions and other forms)
240 J7609 Medications (Injections, infusions and other forms)
240 J7610 Medications (Injections, infusions and other forms)
240 J7611 Medications (Injections, infusions and other forms)
240 J7612 Medications (Injections, infusions and other forms)
240 J7613 Medications (Injections, infusions and other forms)
240 J7614 Medications (Injections, infusions and other forms)
240 J7615 Medications (Injections, infusions and other forms)
240 J7618 Medications (Injections, infusions and other forms)
240 J7620 Medications (Injections, infusions and other forms)
240 J7621 Medications (Injections, infusions and other forms)
240 J7622 Medications (Injections, infusions and other forms)
240 J7624 Medications (Injections, infusions and other forms)
240 J7626 Medications (Injections, infusions and other forms)
240 J7627 Medications (Injections, infusions and other forms)
240 J7628 Medications (Injections, infusions and other forms)
240 J7629 Medications (Injections, infusions and other forms)
240 J7631 Medications (Injections, infusions and other forms)
240 J7632 Medications (Injections, infusions and other forms)
240 J7633 Medications (Injections, infusions and other forms)
240 J7634 Medications (Injections, infusions and other forms)
240 J7635 Medications (Injections, infusions and other forms)
240 J7636 Medications (Injections, infusions and other forms)
240 J7637 Medications (Injections, infusions and other forms)
240 J7638 Medications (Injections, infusions and other forms)
240 J7639 Medications (Injections, infusions and other forms)
240 J7640 Medications (Injections, infusions and other forms)
240 J7641 Medications (Injections, infusions and other forms)
240 J7642 Medications (Injections, infusions and other forms)
240 J7643 Medications (Injections, infusions and other forms)
240 J7644 Medications (Injections, infusions and other forms)
240 J7645 Medications (Injections, infusions and other forms)
240 J7647 Medications (Injections, infusions and other forms)
240 J7648 Medications (Injections, infusions and other forms)
240 J7649 Medications (Injections, infusions and other forms)
240 J7650 Medications (Injections, infusions and other forms)
240 J7657 Medications (Injections, infusions and other forms)
240 J7658 Medications (Injections, infusions and other forms)
240 J7659 Medications (Injections, infusions and other forms)
240 J7660 Medications (Injections, infusions and other forms)
240 J7665 Medications (Injections, infusions and other forms)
240 J7667 Medications (Injections, infusions and other forms)
240 J7668 Medications (Injections, infusions and other forms)
Blue Cross NC Proprietary and Confidential 172 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
240 J7669 Medications (Injections, infusions and other forms)
240 J7670 Medications (Injections, infusions and other forms)
240 J7674 Medications (Injections, infusions and other forms)
240 J7676 Medications (Injections, infusions and other forms)
240 J7677 Medications (Injections, infusions and other forms)
240 J7680 Medications (Injections, infusions and other forms)
240 J7681 Medications (Injections, infusions and other forms)
240 J7682 Medications (Injections, infusions and other forms)
240 J7683 Medications (Injections, infusions and other forms)
240 J7684 Medications (Injections, infusions and other forms)
240 J7685 Medications (Injections, infusions and other forms)
240 J7686 Medications (Injections, infusions and other forms)
240 J7699 Medications (Injections, infusions and other forms)
240 J7799 Medications (Injections, infusions and other forms)
240 J7999 Medications (Injections, infusions and other forms)
240 J8498 Medications (Injections, infusions and other forms)
240 J8499 Medications (Injections, infusions and other forms)
240 J8501 Medications (Injections, infusions and other forms)
240 J8510 Medications (Injections, infusions and other forms)
240 J8515 Medications (Injections, infusions and other forms)
240 J8520 Medications (Injections, infusions and other forms)
240 J8521 Medications (Injections, infusions and other forms)
240 J8530 Medications (Injections, infusions and other forms)
240 J8540 Medications (Injections, infusions and other forms)
240 J8560 Medications (Injections, infusions and other forms)
240 J8562 Medications (Injections, infusions and other forms)
240 J8565 Medications (Injections, infusions and other forms)
240 J8597 Medications (Injections, infusions and other forms)
240 J8600 Medications (Injections, infusions and other forms)
240 J8610 Medications (Injections, infusions and other forms)
240 J8650 Medications (Injections, infusions and other forms)
240 J8655 Medications (Injections, infusions and other forms)
240 J8670 Medications (Injections, infusions and other forms)
240 J8700 Medications (Injections, infusions and other forms)
240 J8705 Medications (Injections, infusions and other forms)
240 J8999 Medications (Injections, infusions and other forms)
240 J9000 Medications (Injections, infusions and other forms)
240 J9015 Medications (Injections, infusions and other forms)
240 J9017 Medications (Injections, infusions and other forms)
240 J9019 Medications (Injections, infusions and other forms)
240 J9020 Medications (Injections, infusions and other forms)
240 J9022 Medications (Injections, infusions and other forms)
240 J9023 Medications (Injections, infusions and other forms)
240 J9025 Medications (Injections, infusions and other forms)
240 J9027 Medications (Injections, infusions and other forms)
240 J9030 Medications (Injections, infusions and other forms)
240 J9032 Medications (Injections, infusions and other forms)
240 J9033 Medications (Injections, infusions and other forms)
240 J9034 Medications (Injections, infusions and other forms)
240 J9035 Medications (Injections, infusions and other forms)
240 J9036 Medications (Injections, infusions and other forms)
240 J9039 Medications (Injections, infusions and other forms)
240 J9040 Medications (Injections, infusions and other forms)
240 J9041 Medications (Injections, infusions and other forms)
240 J9042 Medications (Injections, infusions and other forms)
240 J9043 Medications (Injections, infusions and other forms)
240 J9044 Medications (Injections, infusions and other forms)
240 J9045 Medications (Injections, infusions and other forms)
240 J9047 Medications (Injections, infusions and other forms)
240 J9050 Medications (Injections, infusions and other forms)
240 J9055 Medications (Injections, infusions and other forms)
240 J9057 Medications (Injections, infusions and other forms)
240 J9060 Medications (Injections, infusions and other forms)
240 J9065 Medications (Injections, infusions and other forms)
240 J9070 Medications (Injections, infusions and other forms)
240 J9098 Medications (Injections, infusions and other forms)
240 J9100 Medications (Injections, infusions and other forms)
240 J9118 Medications (Injections, infusions and other forms)
240 J9119 Medications (Injections, infusions and other forms)
240 J9120 Medications (Injections, infusions and other forms)
240 J9130 Medications (Injections, infusions and other forms)
240 J9145 Medications (Injections, infusions and other forms)
240 J9150 Medications (Injections, infusions and other forms)
240 J9151 Medications (Injections, infusions and other forms)
Blue Cross NC Proprietary and Confidential 173 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
240 J9153 Medications (Injections, infusions and other forms)
240 J9155 Medications (Injections, infusions and other forms)
240 J9160 Medications (Injections, infusions and other forms)
240 J9165 Medications (Injections, infusions and other forms)
240 J9171 Medications (Injections, infusions and other forms)
240 J9173 Medications (Injections, infusions and other forms)
240 J9175 Medications (Injections, infusions and other forms)
240 J9176 Medications (Injections, infusions and other forms)
240 J9178 Medications (Injections, infusions and other forms)
240 J9179 Medications (Injections, infusions and other forms)
240 J9181 Medications (Injections, infusions and other forms)
240 J9185 Medications (Injections, infusions and other forms)
240 J9190 Medications (Injections, infusions and other forms)
240 J9199 Medications (Injections, infusions and other forms)
240 J9200 Medications (Injections, infusions and other forms)
240 J9201 Medications (Injections, infusions and other forms)
240 J9202 Medications (Injections, infusions and other forms)
240 J9203 Medications (Injections, infusions and other forms)
240 J9204 Medications (Injections, infusions and other forms)
240 J9205 Medications (Injections, infusions and other forms)
240 J9206 Medications (Injections, infusions and other forms)
240 J9207 Medications (Injections, infusions and other forms)
240 J9208 Medications (Injections, infusions and other forms)
240 J9209 Medications (Injections, infusions and other forms)
240 J9210 Medications (Injections, infusions and other forms)
240 J9211 Medications (Injections, infusions and other forms)
240 J9212 Medications (Injections, infusions and other forms)
240 J9213 Medications (Injections, infusions and other forms)
240 J9214 Medications (Injections, infusions and other forms)
240 J9215 Medications (Injections, infusions and other forms)
240 J9216 Medications (Injections, infusions and other forms)
240 J9217 Medications (Injections, infusions and other forms)
240 J9218 Medications (Injections, infusions and other forms)
240 J9219 Medications (Injections, infusions and other forms)
240 J9225 Medications (Injections, infusions and other forms)
240 J9226 Medications (Injections, infusions and other forms)
240 J9228 Medications (Injections, infusions and other forms)
240 J9229 Medications (Injections, infusions and other forms)
240 J9230 Medications (Injections, infusions and other forms)
240 J9245 Medications (Injections, infusions and other forms)
240 J9250 Medications (Injections, infusions and other forms)
240 J9260 Medications (Injections, infusions and other forms)
240 J9261 Medications (Injections, infusions and other forms)
240 J9262 Medications (Injections, infusions and other forms)
240 J9263 Medications (Injections, infusions and other forms)
240 J9264 Medications (Injections, infusions and other forms)
240 J9266 Medications (Injections, infusions and other forms)
240 J9267 Medications (Injections, infusions and other forms)
240 J9268 Medications (Injections, infusions and other forms)
240 J9269 Medications (Injections, infusions and other forms)
240 J9270 Medications (Injections, infusions and other forms)
240 J9271 Medications (Injections, infusions and other forms)
240 J9280 Medications (Injections, infusions and other forms)
240 J9285 Medications (Injections, infusions and other forms)
240 J9293 Medications (Injections, infusions and other forms)
240 J9295 Medications (Injections, infusions and other forms)
240 J9299 Medications (Injections, infusions and other forms)
240 J9301 Medications (Injections, infusions and other forms)
240 J9302 Medications (Injections, infusions and other forms)
240 J9303 Medications (Injections, infusions and other forms)
240 J9305 Medications (Injections, infusions and other forms)
240 J9306 Medications (Injections, infusions and other forms)
240 J9307 Medications (Injections, infusions and other forms)
240 J9308 Medications (Injections, infusions and other forms)
240 J9309 Medications (Injections, infusions and other forms)
240 J9310 Medications (Injections, infusions and other forms)
240 J9311 Medications (Injections, infusions and other forms)
240 J9312 Medications (Injections, infusions and other forms)
240 J9313 Medications (Injections, infusions and other forms)
240 J9315 Medications (Injections, infusions and other forms)
240 J9320 Medications (Injections, infusions and other forms)
240 J9325 Medications (Injections, infusions and other forms)
240 J9328 Medications (Injections, infusions and other forms)
240 J9330 Medications (Injections, infusions and other forms)
Blue Cross NC Proprietary and Confidential 174 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
240 J9340 Medications (Injections, infusions and other forms)
240 J9351 Medications (Injections, infusions and other forms)
240 J9352 Medications (Injections, infusions and other forms)
240 J9354 Medications (Injections, infusions and other forms)
240 J9355 Medications (Injections, infusions and other forms)
240 J9356 Medications (Injections, infusions and other forms)
240 J9357 Medications (Injections, infusions and other forms)
240 J9360 Medications (Injections, infusions and other forms)
240 J9370 Medications (Injections, infusions and other forms)
240 J9371 Medications (Injections, infusions and other forms)
240 J9390 Medications (Injections, infusions and other forms)
240 J9395 Medications (Injections, infusions and other forms)
240 J9400 Medications (Injections, infusions and other forms)
240 J9600 Medications (Injections, infusions and other forms)
240 J9999 Medications (Injections, infusions and other forms)
243V K0001 DME and supplies-Vendor
243V K0002 DME and supplies-Vendor
243V K0003 DME and supplies-Vendor
243V K0004 DME and supplies-Vendor
243V K0005 DME and supplies-Vendor
243V K0006 DME and supplies-Vendor
243V K0007 DME and supplies-Vendor
243V K0008 DME and supplies-Vendor
243V K0008 DME and supplies-Vendor
243V K0009 DME and supplies-Vendor
243V K0010 DME and supplies-Vendor
243V K0011 DME and supplies-Vendor
243V K0012 DME and supplies-Vendor
243V K0013 DME and supplies-Vendor
243V K0014 DME and supplies-Vendor
243V K0015 DME and supplies-Vendor
243V K0017 DME and supplies-Vendor
243V K0018 DME and supplies-Vendor
243V K0019 DME and supplies-Vendor
243V K0020 DME and supplies-Vendor
243V K0037 DME and supplies-Vendor
243V K0038 DME and supplies-Vendor
243V K0039 DME and supplies-Vendor
243V K0040 DME and supplies-Vendor
243V K0041 DME and supplies-Vendor
243V K0042 DME and supplies-Vendor
243V K0043 DME and supplies-Vendor
243V K0044 DME and supplies-Vendor
243V K0045 DME and supplies-Vendor
243V K0046 DME and supplies-Vendor
243V K0047 DME and supplies-Vendor
243V K0050 DME and supplies-Vendor
243V K0051 DME and supplies-Vendor
243V K0052 DME and supplies-Vendor
243V K0053 DME and supplies-Vendor
243V K0056 DME and supplies-Vendor
243V K0065 DME and supplies-Vendor
243V K0069 DME and supplies-Vendor
243V K0070 DME and supplies-Vendor
243V K0071 DME and supplies-Vendor
243V K0072 DME and supplies-Vendor
243V K0073 DME and supplies-Vendor
243V K0077 DME and supplies-Vendor
243V K0098 DME and supplies-Vendor
243V K0099 DME and supplies-Vendor
243V K0105 DME and supplies-Vendor
243V K0108 DME and supplies-Vendor
243V K0195 DME and supplies-Vendor
243V K0455 DME and supplies-Vendor
243V K0462 DME and supplies-Vendor
243V K0552 DME and supplies-Vendor
243V K0553 DME and supplies-Vendor
243V K0554 DME and supplies-Vendor
243V K0601 DME and supplies-Vendor
243V K0602 DME and supplies-Vendor
243V K0603 DME and supplies-Vendor
243V K0604 DME and supplies-Vendor
243V K0605 DME and supplies-Vendor
243V K0606 DME and supplies-Vendor
Blue Cross NC Proprietary and Confidential 175 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
243V K0607 DME and supplies-Vendor
243V K0608 DME and supplies-Vendor
243V K0609 DME and supplies-Vendor
243V K0669 DME and supplies-Vendor
243V K0672 DME and supplies-Vendor
243V K0730 DME and supplies-Vendor
243V K0733 DME and supplies-Vendor
243V K0740 DME and supplies-Vendor
243V K0743 DME and supplies-Vendor
243V K0744 DME and supplies-Vendor
243V K0745 DME and supplies-Vendor
243V K0746 DME and supplies-Vendor
243V K0800 DME and supplies-Vendor
243V K0801 DME and supplies-Vendor
243V K0802 DME and supplies-Vendor
243V K0806 DME and supplies-Vendor
243V K0807 DME and supplies-Vendor
243V K0808 DME and supplies-Vendor
243V K0812 DME and supplies-Vendor
243V K0813 DME and supplies-Vendor
243V K0814 DME and supplies-Vendor
243V K0815 DME and supplies-Vendor
243V K0816 DME and supplies-Vendor
243V K0820 DME and supplies-Vendor
243V K0821 DME and supplies-Vendor
243V K0822 DME and supplies-Vendor
243V K0823 DME and supplies-Vendor
243V K0824 DME and supplies-Vendor
243V K0825 DME and supplies-Vendor
243V K0826 DME and supplies-Vendor
243V K0827 DME and supplies-Vendor
243V K0828 DME and supplies-Vendor
243V K0829 DME and supplies-Vendor
243V K0830 DME and supplies-Vendor
243V K0831 DME and supplies-Vendor
243V K0835 DME and supplies-Vendor
243V K0836 DME and supplies-Vendor
243V K0837 DME and supplies-Vendor
243V K0838 DME and supplies-Vendor
243V K0839 DME and supplies-Vendor
243V K0840 DME and supplies-Vendor
243V K0841 DME and supplies-Vendor
243V K0842 DME and supplies-Vendor
243V K0843 DME and supplies-Vendor
243V K0848 DME and supplies-Vendor
243V K0849 DME and supplies-Vendor
243V K0850 DME and supplies-Vendor
243V K0851 DME and supplies-Vendor
243V K0852 DME and supplies-Vendor
243V K0853 DME and supplies-Vendor
243V K0854 DME and supplies-Vendor
243V K0855 DME and supplies-Vendor
243V K0856 DME and supplies-Vendor
243V K0857 DME and supplies-Vendor
243V K0858 DME and supplies-Vendor
243V K0859 DME and supplies-Vendor
243V K0860 DME and supplies-Vendor
243V K0861 DME and supplies-Vendor
243V K0862 DME and supplies-Vendor
243V K0863 DME and supplies-Vendor
243V K0864 DME and supplies-Vendor
243V K0868 DME and supplies-Vendor
243V K0869 DME and supplies-Vendor
243V K0870 DME and supplies-Vendor
243V K0871 DME and supplies-Vendor
243V K0877 DME and supplies-Vendor
243V K0878 DME and supplies-Vendor
243V K0879 DME and supplies-Vendor
243V K0880 DME and supplies-Vendor
243V K0884 DME and supplies-Vendor
243V K0885 DME and supplies-Vendor
243V K0886 DME and supplies-Vendor
243V K0890 DME and supplies-Vendor
243V K0891 DME and supplies-Vendor
Blue Cross NC Proprietary and Confidential 176 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
243V K0898 DME and supplies-Vendor
243V K0899 DME and supplies-Vendor
243V K0900 DME and supplies-Vendor
243V K1001 DME and supplies-Vendor
243V K1002 DME and supplies-Vendor
243V K1003 DME and supplies-Vendor
243V K1004 DME and supplies-Vendor
243V K1005 DME and supplies-Vendor
243 L0112 DME and supplies
243 L0113 DME and supplies
243 L0120 DME and supplies
243 L0130 DME and supplies
243 L0140 DME and supplies
243 L0150 DME and supplies
243 L0160 DME and supplies
243 L0170 DME and supplies
243 L0172 DME and supplies
243 L0174 DME and supplies
243V L0180 DME and supplies-Vendor
243V L0190 DME and supplies-Vendor
243V L0200 DME and supplies-Vendor
243V L0220 DME and supplies-Vendor
243 L0450 DME and supplies
243V L0452 DME and supplies-Vendor
243V L0454 DME and supplies-Vendor
243 L0455 DME and supplies
243V L0456 DME and supplies-Vendor
243 L0457 DME and supplies
243 L0458 DME and supplies
243V L0460 DME and supplies-Vendor
243 L0462 DME and supplies
243 L0464 DME and supplies
243V L0466 DME and supplies-Vendor
243 L0467 DME and supplies
243V L0468 DME and supplies-Vendor
243 L0469 DME and supplies
243 L0470 DME and supplies
243 L0472 DME and supplies
243V L0480 DME and supplies-Vendor
243V L0482 DME and supplies-Vendor
243V L0484 DME and supplies-Vendor
243V L0486 DME and supplies-Vendor
243 L0488 DME and supplies
243 L0490 DME and supplies
243 L0491 DME and supplies
243 L0492 DME and supplies
243 L0621 DME and supplies
243V L0622 DME and supplies-Vendor
243 L0623 DME and supplies
243V L0624 DME and supplies-Vendor
243 L0625 DME and supplies
243V L0626 DME and supplies-Vendor
243V L0627 DME and supplies-Vendor
243 L0628 DME and supplies
243V L0629 DME and supplies-Vendor
243V L0630 DME and supplies-Vendor
243V L0631 DME and supplies-Vendor
243V L0632 DME and supplies-Vendor
243V L0633 DME and supplies-Vendor
243V L0634 DME and supplies-Vendor
243 L0635 DME and supplies
243V L0636 DME and supplies-Vendor
243V L0637 DME and supplies-Vendor
243V L0638 DME and supplies-Vendor
243V L0639 DME and supplies-Vendor
243V L0640 DME and supplies-Vendor
243V L0641 DME and supplies-Vendor
243V L0642 DME and supplies-Vendor
243V L0643 DME and supplies-Vendor
243V L0648 DME and supplies-Vendor
243V L0649 DME and supplies-Vendor
243V L0650 DME and supplies-Vendor
243V L0651 DME and supplies-Vendor
243V L0700 DME and supplies-Vendor
Blue Cross NC Proprietary and Confidential 177 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
243V L0710 DME and supplies-Vendor
243V L0810 DME and supplies-Vendor
243V L0820 DME and supplies-Vendor
243V L0830 DME and supplies-Vendor
243V L0859 DME and supplies-Vendor
243V L0861 DME and supplies-Vendor
243V L0970 DME and supplies-Vendor
243V L0972 DME and supplies-Vendor
243V L0974 DME and supplies-Vendor
243V L0976 DME and supplies-Vendor
243V L0978 DME and supplies-Vendor
243V L0980 DME and supplies-Vendor
243V L0982 DME and supplies-Vendor
243V L0984 DME and supplies-Vendor
243V L0999 DME and supplies-Vendor
243V L1000 DME and supplies-Vendor
243 L1001 DME and supplies
243V L1005 DME and supplies-Vendor
243V L1010 DME and supplies-Vendor
243V L1020 DME and supplies-Vendor
243V L1025 DME and supplies-Vendor
243V L1030 DME and supplies-Vendor
243V L1040 DME and supplies-Vendor
243V L1050 DME and supplies-Vendor
243V L1060 DME and supplies-Vendor
243V L1070 DME and supplies-Vendor
243V L1080 DME and supplies-Vendor
243V L1085 DME and supplies-Vendor
243V L1090 DME and supplies-Vendor
243V L1100 DME and supplies-Vendor
243V L1110 DME and supplies-Vendor
243V L1120 DME and supplies-Vendor
243V L1200 DME and supplies-Vendor
243V L1210 DME and supplies-Vendor
243V L1220 DME and supplies-Vendor
243V L1230 DME and supplies-Vendor
243V L1240 DME and supplies-Vendor
243V L1250 DME and supplies-Vendor
243V L1260 DME and supplies-Vendor
243V L1270 DME and supplies-Vendor
243V L1280 DME and supplies-Vendor
243V L1290 DME and supplies-Vendor
243V L1300 DME and supplies-Vendor
243V L1310 DME and supplies-Vendor
243V L1499 DME and supplies-Vendor
243V L1600 DME and supplies-Vendor
243V L1610 DME and supplies-Vendor
243V L1620 DME and supplies-Vendor
243V L1630 DME and supplies-Vendor
243V L1640 DME and supplies-Vendor
243 L1650 DME and supplies
243 L1652 DME and supplies
243 L1660 DME and supplies
243V L1680 DME and supplies-Vendor
243V L1685 DME and supplies-Vendor
243 L1686 DME and supplies
243 L1690 DME and supplies
243V L1700 DME and supplies-Vendor
243V L1710 DME and supplies-Vendor
243V L1720 DME and supplies-Vendor
243V L1730 DME and supplies-Vendor
243V L1755 DME and supplies-Vendor
243V L1810 DME and supplies-Vendor
243 L1812 DME and supplies
243 L1820 DME and supplies
243 L1830 DME and supplies
243 L1831 DME and supplies
243V L1832 DME and supplies-Vendor
243 L1833 DME and supplies
243V L1834 DME and supplies-Vendor
243 L1836 DME and supplies
243V L1840 DME and supplies-Vendor
243V L1843 DME and supplies-Vendor
243V L1844 DME and supplies-Vendor
Blue Cross NC Proprietary and Confidential 178 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
243V L1845 DME and supplies-Vendor
243V L1846 DME and supplies-Vendor
243V L1847 DME and supplies-Vendor
243 L1848 DME and supplies
243 L1850 DME and supplies
243 L1851 DME and supplies
243 L1852 DME and supplies
243V L1860 DME and supplies-Vendor
243V L1900 DME and supplies-Vendor
243 L1902 DME and supplies
243V L1904 DME and supplies-Vendor
243 L1906 DME and supplies
243V L1907 DME and supplies-Vendor
243V L1910 DME and supplies-Vendor
243V L1920 DME and supplies-Vendor
243 L1930 DME and supplies
243 L1932 DME and supplies
243V L1940 DME and supplies-Vendor
243V L1945 DME and supplies-Vendor
243V L1950 DME and supplies-Vendor
243 L1951 DME and supplies
243V L1960 DME and supplies-Vendor
243V L1970 DME and supplies-Vendor
243 L1971 DME and supplies
243V L1980 DME and supplies-Vendor
243V L1990 DME and supplies-Vendor
243V L2000 DME and supplies-Vendor
243V L2005 DME and supplies-Vendor
243V L2006 DME and supplies-Vendor
243V L2010 DME and supplies-Vendor
243V L2020 DME and supplies-Vendor
243V L2030 DME and supplies-Vendor
243V L2034 DME and supplies-Vendor
243 L2035 DME and supplies
243V L2036 DME and supplies-Vendor
243V L2037 DME and supplies-Vendor
243V L2038 DME and supplies-Vendor
243V L2040 DME and supplies-Vendor
243V L2050 DME and supplies-Vendor
243V L2060 DME and supplies-Vendor
243V L2070 DME and supplies-Vendor
243V L2080 DME and supplies-Vendor
243V L2090 DME and supplies-Vendor
243V L2106 DME and supplies-Vendor
243V L2108 DME and supplies-Vendor
243 L2112 DME and supplies
243 L2114 DME and supplies
243 L2116 DME and supplies
243V L2126 DME and supplies-Vendor
243V L2128 DME and supplies-Vendor
243 L2132 DME and supplies
243 L2134 DME and supplies
243 L2136 DME and supplies
243V L2180 DME and supplies-Vendor
243V L2182 DME and supplies-Vendor
243V L2184 DME and supplies-Vendor
243V L2186 DME and supplies-Vendor
243V L2188 DME and supplies-Vendor
243V L2190 DME and supplies-Vendor
243V L2192 DME and supplies-Vendor
243V L2200 DME and supplies-Vendor
243V L2210 DME and supplies-Vendor
243V L2220 DME and supplies-Vendor
243V L2230 DME and supplies-Vendor
243V L2232 DME and supplies-Vendor
243V L2240 DME and supplies-Vendor
243V L2250 DME and supplies-Vendor
243V L2260 DME and supplies-Vendor
243V L2265 DME and supplies-Vendor
243V L2270 DME and supplies-Vendor
243V L2275 DME and supplies-Vendor
243V L2280 DME and supplies-Vendor
243V L2300 DME and supplies-Vendor
243V L2310 DME and supplies-Vendor
Blue Cross NC Proprietary and Confidential 179 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
243V L2320 DME and supplies-Vendor
243V L2330 DME and supplies-Vendor
243V L2335 DME and supplies-Vendor
243V L2340 DME and supplies-Vendor
243V L2350 DME and supplies-Vendor
243V L2360 DME and supplies-Vendor
243V L2370 DME and supplies-Vendor
243V L2375 DME and supplies-Vendor
243V L2380 DME and supplies-Vendor
243V L2385 DME and supplies-Vendor
243V L2387 DME and supplies-Vendor
243V L2390 DME and supplies-Vendor
243V L2395 DME and supplies-Vendor
243V L2397 DME and supplies-Vendor
243V L2405 DME and supplies-Vendor
243V L2415 DME and supplies-Vendor
243V L2425 DME and supplies-Vendor
243V L2430 DME and supplies-Vendor
243V L2492 DME and supplies-Vendor
243V L2500 DME and supplies-Vendor
243V L2510 DME and supplies-Vendor
243V L2520 DME and supplies-Vendor
243V L2525 DME and supplies-Vendor
243V L2526 DME and supplies-Vendor
243V L2530 DME and supplies-Vendor
243V L2540 DME and supplies-Vendor
243V L2550 DME and supplies-Vendor
243V L2570 DME and supplies-Vendor
243V L2580 DME and supplies-Vendor
243V L2600 DME and supplies-Vendor
243V L2610 DME and supplies-Vendor
243V L2620 DME and supplies-Vendor
243V L2622 DME and supplies-Vendor
243V L2624 DME and supplies-Vendor
243V L2627 DME and supplies-Vendor
243V L2628 DME and supplies-Vendor
243V L2630 DME and supplies-Vendor
243V L2640 DME and supplies-Vendor
243V L2650 DME and supplies-Vendor
243V L2660 DME and supplies-Vendor
243V L2670 DME and supplies-Vendor
243V L2680 DME and supplies-Vendor
243V L2750 DME and supplies-Vendor
243V L2755 DME and supplies-Vendor
243V L2760 DME and supplies-Vendor
243V L2768 DME and supplies-Vendor
243V L2780 DME and supplies-Vendor
243V L2785 DME and supplies-Vendor
243V L2795 DME and supplies-Vendor
243V L2800 DME and supplies-Vendor
243V L2810 DME and supplies-Vendor
243V L2820 DME and supplies-Vendor
243V L2830 DME and supplies-Vendor
243V L2840 DME and supplies-Vendor
243V L2850 DME and supplies-Vendor
243V L2861 DME and supplies-Vendor
243V L2999 DME and supplies-Vendor
243 L3000 DME and supplies
243 L3001 DME and supplies
243 L3002 DME and supplies
243 L3003 DME and supplies
243 L3010 DME and supplies
243 L3020 DME and supplies
243 L3030 DME and supplies
243V L3031 DME and supplies-Vendor
243 L3040 DME and supplies
243 L3050 DME and supplies
243 L3060 DME and supplies
243 L3070 DME and supplies
243 L3080 DME and supplies
243 L3090 DME and supplies
243 L3100 DME and supplies
243 L3140 DME and supplies
243 L3150 DME and supplies
Blue Cross NC Proprietary and Confidential 180 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
243 L3160 DME and supplies
243 L3170 DME and supplies
243 L3201 DME and supplies
243 L3202 DME and supplies
243 L3203 DME and supplies
243 L3204 DME and supplies
243 L3206 DME and supplies
243 L3207 DME and supplies
243 L3208 DME and supplies
243 L3209 DME and supplies
243 L3211 DME and supplies
243 L3212 DME and supplies
243 L3213 DME and supplies
243 L3214 DME and supplies
243 L3215 DME and supplies
243 L3216 DME and supplies
243 L3217 DME and supplies
243 L3219 DME and supplies
243 L3221 DME and supplies
243 L3222 DME and supplies
243 L3224 DME and supplies
243 L3225 DME and supplies
243 L3230 DME and supplies
243 L3250 DME and supplies
243 L3251 DME and supplies
243 L3252 DME and supplies
243 L3253 DME and supplies
243 L3254 DME and supplies
243 L3255 DME and supplies
243 L3257 DME and supplies
243 L3260 DME and supplies
243 L3265 DME and supplies
243 L3300 DME and supplies
243 L3310 DME and supplies
243 L3320 DME and supplies
243 L3330 DME and supplies
243 L3332 DME and supplies
243 L3334 DME and supplies
243 L3340 DME and supplies
243 L3350 DME and supplies
243 L3360 DME and supplies
243 L3370 DME and supplies
243 L3380 DME and supplies
243 L3390 DME and supplies
243 L3400 DME and supplies
243 L3410 DME and supplies
243 L3420 DME and supplies
243 L3430 DME and supplies
243 L3440 DME and supplies
243 L3450 DME and supplies
243 L3455 DME and supplies
243 L3460 DME and supplies
243 L3465 DME and supplies
243 L3470 DME and supplies
243 L3480 DME and supplies
243 L3485 DME and supplies
243 L3500 DME and supplies
243 L3510 DME and supplies
243 L3520 DME and supplies
243 L3530 DME and supplies
243 L3540 DME and supplies
243 L3550 DME and supplies
243 L3560 DME and supplies
243 L3570 DME and supplies
243 L3580 DME and supplies
243 L3590 DME and supplies
243 L3595 DME and supplies
243 L3600 DME and supplies
243 L3610 DME and supplies
243 L3620 DME and supplies
243 L3630 DME and supplies
243 L3640 DME and supplies
243 L3649 DME and supplies
243 L3650 DME and supplies
Blue Cross NC Proprietary and Confidential 181 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
243 L3660 DME and supplies
243V L3670 DME and supplies-Vendor
243V L3671 DME and supplies-Vendor
243 L3674 DME and supplies
243 L3675 DME and supplies
243V L3677 DME and supplies-Vendor
243 L3678 DME and supplies
243V L3702 DME and supplies-Vendor
243 L3710 DME and supplies
243V L3720 DME and supplies-Vendor
243V L3730 DME and supplies-Vendor
243V L3740 DME and supplies-Vendor
243V L3760 DME and supplies-Vendor
243 L3761 DME and supplies
243 L3762 DME and supplies
243V L3763 DME and supplies-Vendor
243V L3764 DME and supplies-Vendor
243V L3765 DME and supplies-Vendor
243V L3766 DME and supplies-Vendor
243V L3806 DME and supplies-Vendor
243 L3807 DME and supplies
243V L3808 DME and supplies-Vendor
243 L3809 DME and supplies
243V L3891 DME and supplies-Vendor
243V L3900 DME and supplies-Vendor
243V L3901 DME and supplies-Vendor
243V L3904 DME and supplies-Vendor
243V L3905 DME and supplies-Vendor
243V L3906 DME and supplies-Vendor
243 L3908 DME and supplies
243 L3912 DME and supplies
243V L3913 DME and supplies-Vendor
243 L3915 DME and supplies
243 L3916 DME and supplies
243 L3917 DME and supplies
243 L3918 DME and supplies
243V L3919 DME and supplies-Vendor
243V L3921 DME and supplies-Vendor
243 L3923 DME and supplies
243 L3924 DME and supplies
243 L3925 DME and supplies
243 L3927 DME and supplies
243 L3929 DME and supplies
243 L3930 DME and supplies
243 L3931 DME and supplies
243V L3933 DME and supplies-Vendor
243V L3935 DME and supplies-Vendor
243V L3956 DME and supplies-Vendor
243 L3960 DME and supplies
243V L3961 DME and supplies-Vendor
243 L3962 DME and supplies
243V L3967 DME and supplies-Vendor
243V L3971 DME and supplies-Vendor
243V L3973 DME and supplies-Vendor
243V L3975 DME and supplies-Vendor
243V L3976 DME and supplies-Vendor
243V L3977 DME and supplies-Vendor
243V L3978 DME and supplies-Vendor
243 L3980 DME and supplies
243 L3981 DME and supplies
243 L3982 DME and supplies
243 L3984 DME and supplies
243 L3995 DME and supplies
243V L3999 DME and supplies-Vendor
243V L4000 DME and supplies-Vendor
243V L4002 DME and supplies-Vendor
243V L4010 DME and supplies-Vendor
243V L4020 DME and supplies-Vendor
243V L4030 DME and supplies-Vendor
243V L4040 DME and supplies-Vendor
243V L4045 DME and supplies-Vendor
243V L4050 DME and supplies-Vendor
243V L4055 DME and supplies-Vendor
243V L4060 DME and supplies-Vendor
Blue Cross NC Proprietary and Confidential 182 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
243V L4070 DME and supplies-Vendor
243V L4080 DME and supplies-Vendor
243V L4090 DME and supplies-Vendor
243V L4100 DME and supplies-Vendor
243V L4110 DME and supplies-Vendor
243V L4130 DME and supplies-Vendor
243V L4205 DME and supplies-Vendor
243V L4210 DME and supplies-Vendor
243 L4350 DME and supplies
243 L4360 DME and supplies
243 L4361 DME and supplies
243 L4370 DME and supplies
243 L4386 DME and supplies
243 L4387 DME and supplies
243 L4392 DME and supplies
243 L4394 DME and supplies
243V L4396 DME and supplies-Vendor
243 L4397 DME and supplies
243 L4398 DME and supplies
243V L4631 DME and supplies-Vendor
243V L5000 DME and supplies-Vendor
243V L5010 DME and supplies-Vendor
243V L5020 DME and supplies-Vendor
243V L5050 DME and supplies-Vendor
243V L5060 DME and supplies-Vendor
243V L5100 DME and supplies-Vendor
243V L5105 DME and supplies-Vendor
243V L5150 DME and supplies-Vendor
243V L5160 DME and supplies-Vendor
243V L5200 DME and supplies-Vendor
243V L5210 DME and supplies-Vendor
243V L5220 DME and supplies-Vendor
243V L5230 DME and supplies-Vendor
243V L5250 DME and supplies-Vendor
243V L5270 DME and supplies-Vendor
243V L5280 DME and supplies-Vendor
243V L5301 DME and supplies-Vendor
243V L5312 DME and supplies-Vendor
243V L5321 DME and supplies-Vendor
243V L5331 DME and supplies-Vendor
243V L5341 DME and supplies-Vendor
243V L5400 DME and supplies-Vendor
243V L5410 DME and supplies-Vendor
243V L5420 DME and supplies-Vendor
243V L5430 DME and supplies-Vendor
243V L5450 DME and supplies-Vendor
243V L5460 DME and supplies-Vendor
243V L5500 DME and supplies-Vendor
243V L5505 DME and supplies-Vendor
243V L5510 DME and supplies-Vendor
243V L5520 DME and supplies-Vendor
243V L5530 DME and supplies-Vendor
243V L5535 DME and supplies-Vendor
243V L5540 DME and supplies-Vendor
243V L5560 DME and supplies-Vendor
243V L5570 DME and supplies-Vendor
243V L5580 DME and supplies-Vendor
243V L5585 DME and supplies-Vendor
243V L5590 DME and supplies-Vendor
243V L5595 DME and supplies-Vendor
243V L5600 DME and supplies-Vendor
243V L5610 DME and supplies-Vendor
243V L5611 DME and supplies-Vendor
243V L5613 DME and supplies-Vendor
243V L5614 DME and supplies-Vendor
243V L5616 DME and supplies-Vendor
243V L5617 DME and supplies-Vendor
243V L5618 DME and supplies-Vendor
243V L5620 DME and supplies-Vendor
243V L5622 DME and supplies-Vendor
243V L5624 DME and supplies-Vendor
243V L5626 DME and supplies-Vendor
243V L5628 DME and supplies-Vendor
243V L5629 DME and supplies-Vendor
Blue Cross NC Proprietary and Confidential 183 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
243V L5630 DME and supplies-Vendor
243V L5631 DME and supplies-Vendor
243V L5632 DME and supplies-Vendor
243V L5634 DME and supplies-Vendor
243V L5636 DME and supplies-Vendor
243V L5637 DME and supplies-Vendor
243V L5638 DME and supplies-Vendor
243V L5639 DME and supplies-Vendor
243V L5640 DME and supplies-Vendor
243V L5642 DME and supplies-Vendor
243V L5643 DME and supplies-Vendor
243V L5644 DME and supplies-Vendor
243V L5645 DME and supplies-Vendor
243V L5646 DME and supplies-Vendor
243V L5647 DME and supplies-Vendor
243V L5648 DME and supplies-Vendor
243V L5649 DME and supplies-Vendor
243V L5650 DME and supplies-Vendor
243V L5651 DME and supplies-Vendor
243V L5652 DME and supplies-Vendor
243V L5653 DME and supplies-Vendor
243V L5654 DME and supplies-Vendor
243V L5655 DME and supplies-Vendor
243V L5656 DME and supplies-Vendor
243V L5658 DME and supplies-Vendor
243V L5661 DME and supplies-Vendor
243V L5665 DME and supplies-Vendor
243V L5666 DME and supplies-Vendor
243V L5668 DME and supplies-Vendor
243V L5670 DME and supplies-Vendor
243V L5671 DME and supplies-Vendor
243V L5672 DME and supplies-Vendor
243V L5673 DME and supplies-Vendor
243V L5676 DME and supplies-Vendor
243V L5677 DME and supplies-Vendor
243V L5678 DME and supplies-Vendor
243V L5679 DME and supplies-Vendor
243V L5680 DME and supplies-Vendor
243V L5681 DME and supplies-Vendor
243V L5682 DME and supplies-Vendor
243V L5683 DME and supplies-Vendor
243V L5684 DME and supplies-Vendor
243V L5685 DME and supplies-Vendor
243V L5686 DME and supplies-Vendor
243V L5688 DME and supplies-Vendor
243V L5690 DME and supplies-Vendor
243V L5692 DME and supplies-Vendor
243V L5694 DME and supplies-Vendor
243V L5695 DME and supplies-Vendor
243V L5696 DME and supplies-Vendor
243V L5697 DME and supplies-Vendor
243V L5698 DME and supplies-Vendor
243V L5699 DME and supplies-Vendor
243V L5700 DME and supplies-Vendor
243V L5701 DME and supplies-Vendor
243V L5702 DME and supplies-Vendor
243V L5703 DME and supplies-Vendor
243V L5704 DME and supplies-Vendor
243V L5705 DME and supplies-Vendor
243V L5706 DME and supplies-Vendor
243V L5707 DME and supplies-Vendor
243V L5710 DME and supplies-Vendor
243V L5711 DME and supplies-Vendor
243V L5712 DME and supplies-Vendor
243V L5714 DME and supplies-Vendor
243V L5716 DME and supplies-Vendor
243V L5718 DME and supplies-Vendor
243V L5722 DME and supplies-Vendor
243V L5724 DME and supplies-Vendor
243V L5726 DME and supplies-Vendor
243V L5728 DME and supplies-Vendor
243V L5780 DME and supplies-Vendor
243V L5781 DME and supplies-Vendor
243V L5782 DME and supplies-Vendor
Blue Cross NC Proprietary and Confidential 184 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
243V L5785 DME and supplies-Vendor
243V L5790 DME and supplies-Vendor
243V L5795 DME and supplies-Vendor
243V L5810 DME and supplies-Vendor
243V L5811 DME and supplies-Vendor
243V L5812 DME and supplies-Vendor
243V L5814 DME and supplies-Vendor
243V L5816 DME and supplies-Vendor
243V L5818 DME and supplies-Vendor
243V L5822 DME and supplies-Vendor
243V L5824 DME and supplies-Vendor
243V L5826 DME and supplies-Vendor
243V L5828 DME and supplies-Vendor
243V L5830 DME and supplies-Vendor
243V L5840 DME and supplies-Vendor
243V L5845 DME and supplies-Vendor
243V L5848 DME and supplies-Vendor
243V L5850 DME and supplies-Vendor
243V L5855 DME and supplies-Vendor
243V L5856 DME and supplies-Vendor
243V L5857 DME and supplies-Vendor
243V L5858 DME and supplies-Vendor
243V L5859 DME and supplies-Vendor
243V L5910 DME and supplies-Vendor
243V L5920 DME and supplies-Vendor
243V L5925 DME and supplies-Vendor
243V L5930 DME and supplies-Vendor
243V L5940 DME and supplies-Vendor
243V L5950 DME and supplies-Vendor
243V L5960 DME and supplies-Vendor
243V L5961 DME and supplies-Vendor
243V L5962 DME and supplies-Vendor
243V L5964 DME and supplies-Vendor
243V L5966 DME and supplies-Vendor
243V L5968 DME and supplies-Vendor
243V L5969 DME and supplies-Vendor
243V L5970 DME and supplies-Vendor
243V L5971 DME and supplies-Vendor
243V L5972 DME and supplies-Vendor
243V L5973 DME and supplies-Vendor
243V L5974 DME and supplies-Vendor
243V L5975 DME and supplies-Vendor
243V L5976 DME and supplies-Vendor
243V L5978 DME and supplies-Vendor
243V L5979 DME and supplies-Vendor
243V L5980 DME and supplies-Vendor
243V L5981 DME and supplies-Vendor
243V L5982 DME and supplies-Vendor
243V L5984 DME and supplies-Vendor
243V L5985 DME and supplies-Vendor
243V L5986 DME and supplies-Vendor
243V L5987 DME and supplies-Vendor
243V L5988 DME and supplies-Vendor
243V L5990 DME and supplies-Vendor
243V L5999 DME and supplies-Vendor
243V L6000 DME and supplies-Vendor
243V L6010 DME and supplies-Vendor
243V L6020 DME and supplies-Vendor
243V L6026 DME and supplies-Vendor
243V L6050 DME and supplies-Vendor
243V L6055 DME and supplies-Vendor
243V L6100 DME and supplies-Vendor
243V L6110 DME and supplies-Vendor
243V L6120 DME and supplies-Vendor
243V L6130 DME and supplies-Vendor
243V L6200 DME and supplies-Vendor
243V L6205 DME and supplies-Vendor
243V L6250 DME and supplies-Vendor
243V L6300 DME and supplies-Vendor
243V L6310 DME and supplies-Vendor
243V L6320 DME and supplies-Vendor
243V L6350 DME and supplies-Vendor
243V L6360 DME and supplies-Vendor
243V L6370 DME and supplies-Vendor
Blue Cross NC Proprietary and Confidential 185 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
243V L6380 DME and supplies-Vendor
243V L6382 DME and supplies-Vendor
243V L6384 DME and supplies-Vendor
243V L6386 DME and supplies-Vendor
243V L6388 DME and supplies-Vendor
243V L6400 DME and supplies-Vendor
243V L6450 DME and supplies-Vendor
243V L6500 DME and supplies-Vendor
243V L6550 DME and supplies-Vendor
243V L6570 DME and supplies-Vendor
243V L6580 DME and supplies-Vendor
243V L6582 DME and supplies-Vendor
243V L6584 DME and supplies-Vendor
243V L6586 DME and supplies-Vendor
243V L6588 DME and supplies-Vendor
243V L6590 DME and supplies-Vendor
243V L6600 DME and supplies-Vendor
243V L6605 DME and supplies-Vendor
243V L6610 DME and supplies-Vendor
243V L6611 DME and supplies-Vendor
243V L6615 DME and supplies-Vendor
243V L6616 DME and supplies-Vendor
243V L6620 DME and supplies-Vendor
243V L6621 DME and supplies-Vendor
243V L6623 DME and supplies-Vendor
243V L6624 DME and supplies-Vendor
243V L6625 DME and supplies-Vendor
243V L6628 DME and supplies-Vendor
243V L6629 DME and supplies-Vendor
243V L6630 DME and supplies-Vendor
243V L6632 DME and supplies-Vendor
243V L6635 DME and supplies-Vendor
243V L6637 DME and supplies-Vendor
243V L6638 DME and supplies-Vendor
243V L6640 DME and supplies-Vendor
243V L6641 DME and supplies-Vendor
243V L6642 DME and supplies-Vendor
243V L6645 DME and supplies-Vendor
243V L6646 DME and supplies-Vendor
243V L6647 DME and supplies-Vendor
243V L6648 DME and supplies-Vendor
243V L6650 DME and supplies-Vendor
243V L6655 DME and supplies-Vendor
243V L6660 DME and supplies-Vendor
243V L6665 DME and supplies-Vendor
243V L6670 DME and supplies-Vendor
243V L6672 DME and supplies-Vendor
243V L6675 DME and supplies-Vendor
243V L6676 DME and supplies-Vendor
243V L6677 DME and supplies-Vendor
243V L6680 DME and supplies-Vendor
243V L6682 DME and supplies-Vendor
243V L6684 DME and supplies-Vendor
243V L6686 DME and supplies-Vendor
243V L6687 DME and supplies-Vendor
243V L6688 DME and supplies-Vendor
243V L6689 DME and supplies-Vendor
243V L6690 DME and supplies-Vendor
243V L6691 DME and supplies-Vendor
243V L6692 DME and supplies-Vendor
243V L6693 DME and supplies-Vendor
243V L6694 DME and supplies-Vendor
243V L6695 DME and supplies-Vendor
243V L6696 DME and supplies-Vendor
243V L6697 DME and supplies-Vendor
243V L6698 DME and supplies-Vendor
243V L6703 DME and supplies-Vendor
243V L6704 DME and supplies-Vendor
243V L6706 DME and supplies-Vendor
243V L6707 DME and supplies-Vendor
243V L6708 DME and supplies-Vendor
243V L6709 DME and supplies-Vendor
243V L6711 DME and supplies-Vendor
243V L6712 DME and supplies-Vendor
Blue Cross NC Proprietary and Confidential 186 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
243V L6713 DME and supplies-Vendor
243V L6714 DME and supplies-Vendor
243V L6715 DME and supplies-Vendor
243V L6721 DME and supplies-Vendor
243V L6722 DME and supplies-Vendor
243V L6805 DME and supplies-Vendor
243V L6810 DME and supplies-Vendor
243V L6880 DME and supplies-Vendor
243V L6881 DME and supplies-Vendor
243V L6882 DME and supplies-Vendor
243V L6883 DME and supplies-Vendor
243V L6884 DME and supplies-Vendor
243V L6885 DME and supplies-Vendor
243V L6890 DME and supplies-Vendor
243V L6895 DME and supplies-Vendor
243V L6900 DME and supplies-Vendor
243V L6905 DME and supplies-Vendor
243V L6910 DME and supplies-Vendor
243V L6915 DME and supplies-Vendor
243V L6920 DME and supplies-Vendor
243V L6925 DME and supplies-Vendor
243V L6930 DME and supplies-Vendor
243V L6935 DME and supplies-Vendor
243V L6940 DME and supplies-Vendor
243V L6945 DME and supplies-Vendor
243V L6950 DME and supplies-Vendor
243V L6955 DME and supplies-Vendor
243V L6960 DME and supplies-Vendor
243V L6965 DME and supplies-Vendor
243V L6970 DME and supplies-Vendor
243V L6975 DME and supplies-Vendor
243V L7007 DME and supplies-Vendor
243V L7008 DME and supplies-Vendor
243V L7009 DME and supplies-Vendor
243V L7040 DME and supplies-Vendor
243V L7045 DME and supplies-Vendor
243V L7170 DME and supplies-Vendor
243V L7180 DME and supplies-Vendor
243V L7181 DME and supplies-Vendor
243V L7185 DME and supplies-Vendor
243V L7186 DME and supplies-Vendor
243V L7190 DME and supplies-Vendor
243V L7191 DME and supplies-Vendor
243V L7259 DME and supplies-Vendor
243V L7360 DME and supplies-Vendor
243V L7362 DME and supplies-Vendor
243V L7364 DME and supplies-Vendor
243V L7366 DME and supplies-Vendor
243V L7367 DME and supplies-Vendor
243V L7368 DME and supplies-Vendor
243V L7400 DME and supplies-Vendor
243V L7401 DME and supplies-Vendor
243V L7402 DME and supplies-Vendor
243V L7403 DME and supplies-Vendor
243V L7404 DME and supplies-Vendor
243V L7405 DME and supplies-Vendor
243V L7499 DME and supplies-Vendor
243V L7510 DME and supplies-Vendor
243V L7520 DME and supplies-Vendor
243V L7600 DME and supplies-Vendor
243V L7700 DME and supplies-Vendor
243V L7900 DME and supplies-Vendor
243V L7902 DME and supplies-Vendor
243 L8000 DME and supplies
243 L8001 DME and supplies
243 L8002 DME and supplies
243 L8010 DME and supplies
243 L8015 DME and supplies
243 L8020 DME and supplies
243 L8030 DME and supplies
243 L8031 DME and supplies
243 L8032 DME and supplies
243 L8033 DME and Supplies
243V L8035 DME and supplies-Vendor
Blue Cross NC Proprietary and Confidential 187 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
243 L8039 DME and supplies
243V L8040 DME and supplies-Vendor
243V L8041 DME and supplies-Vendor
243V L8042 DME and supplies-Vendor
243V L8043 DME and supplies-Vendor
243V L8044 DME and supplies-Vendor
243V L8045 DME and supplies-Vendor
243V L8046 DME and supplies-Vendor
243V L8047 DME and supplies-Vendor
243V L8048 DME and supplies-Vendor
243V L8049 DME and supplies-Vendor
243 L8300 DME and supplies
243 L8310 DME and supplies
243 L8320 DME and supplies
243 L8330 DME and supplies
243V L8400 DME and supplies-Vendor
243V L8410 DME and supplies-Vendor
243V L8415 DME and supplies-Vendor
243V L8417 DME and supplies-Vendor
243V L8420 DME and supplies-Vendor
243V L8430 DME and supplies-Vendor
243V L8435 DME and supplies-Vendor
243V L8440 DME and supplies-Vendor
243V L8460 DME and supplies-Vendor
243V L8465 DME and supplies-Vendor
243V L8470 DME and supplies-Vendor
243V L8480 DME and supplies-Vendor
243V L8485 DME and supplies-Vendor
243V L8499 DME and supplies-Vendor
243 L8500 DME and supplies
243 L8501 DME and supplies
243 L8505 DME and supplies
243 L8507 DME and supplies
243 L8509 DME and supplies
243 L8510 DME and supplies
243 L8511 DME and supplies
243 L8512 DME and supplies
243 L8513 DME and supplies
243 L8514 DME and supplies
243 L8515 DME and supplies
243 L8600 DME and supplies
243 L8603 DME and supplies
243 L8604 DME and supplies
243 L8605 DME and supplies
243 L8606 DME and supplies
243 L8607 DME and supplies
243V L8608 DME and supplies-Vendor
243 L8609 DME and supplies
243 L8610 DME and supplies
243 L8612 DME and supplies
243 L8613 DME and supplies
243 L8614 DME and supplies
243 L8615 DME and supplies
243 L8616 DME and supplies
243 L8617 DME and supplies
243 L8618 DME and supplies
243 L8619 DME and supplies
243 L8620 DME and supplies
243 L8621 DME and supplies
243 L8622 DME and supplies
243 L8623 DME and supplies
243 L8624 DME and supplies
243 L8625 DME and supplies
243 L8627 DME and supplies
243 L8628 DME and supplies
243 L8629 DME and supplies
243 L8630 DME and supplies
243 L8631 DME and supplies
243 L8641 DME and supplies
243 L8642 DME and supplies
243 L8658 DME and supplies
243 L8659 DME and supplies
243 L8670 DME and supplies
243 L8679 DME and supplies
Blue Cross NC Proprietary and Confidential 188 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
243 L8680 DME and supplies
243 L8681 DME and supplies
243 L8682 DME and supplies
243 L8683 DME and supplies
243 L8684 DME and supplies
243 L8685 DME and supplies
243 L8686 DME and supplies
243 L8687 DME and supplies
243 L8688 DME and supplies
243 L8689 DME and supplies
243 L8690 DME and supplies
243 L8691 DME and supplies
243 L8692 DME and supplies
243 L8693 DME and supplies
243 L8694 DME and supplies
243 L8695 DME and supplies
243 L8696 DME and supplies
243V L8698 DME and supplies-Vendor
243 L8699 DME and supplies
243V L8701 DME and supplies-Vendor
243V L8702 DME and supplies-Vendor
243 L9900 DME and supplies
231 M0075 Other Therapeutic Procedures
156 M0076 Injections And Aspirations Of Muscles, Tendons, Bursa, Joints And Soft Tissue
93 M0100 Other Non-Or Upper GI Therapeutic Procedures
63 M0300 Other Non-Or Therapeutic Cardiovascular Procedures
61 M0301 Other Or Procedures On Vessels Other Than Head And Neck
233 P2028 Laboratory - Chemistry And Hematology
235 P2029 Other Laboratory
235 P2031 Other Laboratory
233 P2033 Laboratory - Chemistry And Hematology
233 P2038 Laboratory - Chemistry And Hematology
234 P3000 Pathology
234 P3001 Pathology
206 P7001 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
222 P9010 Blood Transfusion
222 P9011 Blood Transfusion
222 P9012 Blood Transfusion
222 P9016 Blood Transfusion
222 P9017 Blood Transfusion
222 P9019 Blood Transfusion
222 P9020 Blood Transfusion
222 P9021 Blood Transfusion
222 P9022 Blood Transfusion
222 P9023 Blood Transfusion
222 P9031 Blood Transfusion
222 P9032 Blood Transfusion
222 P9033 Blood Transfusion
222 P9034 Blood Transfusion
222 P9035 Blood Transfusion
222 P9036 Blood Transfusion
222 P9037 Blood Transfusion
222 P9038 Blood Transfusion
222 P9039 Blood Transfusion
222 P9040 Blood Transfusion
222 P9041 Blood Transfusion
222 P9043 Blood Transfusion
222 P9044 Blood Transfusion
222 P9045 Blood Transfusion
222 P9046 Blood Transfusion
222 P9047 Blood Transfusion
222 P9048 Blood Transfusion
222 P9050 Blood Transfusion
222 P9051 Blood Transfusion
222 P9052 Blood Transfusion
222 P9053 Blood Transfusion
222 P9054 Blood Transfusion
222 P9055 Blood Transfusion
222 P9056 Blood Transfusion
222 P9057 Blood Transfusion
222 P9058 Blood Transfusion
222 P9059 Blood Transfusion
222 P9060 Blood Transfusion
222 P9070 Blood Transfusion
Blue Cross NC Proprietary and Confidential 189 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
222 P9071 Blood Transfusion
222 P9073 Blood Transfusion
222 P9099 Blood Transfusion
222 P9100 Blood Transfusion
239 P9603 Transportation - Patient, Provider, Equipment
239 P9604 Transportation - Patient, Provider, Equipment
110 P9612 Other Diagnostic Procedures Of Urinary Tract
110 P9615 Other Diagnostic Procedures Of Urinary Tract
201 Q0035 Cardiac Stress Tests
231 Q0081 Other Therapeutic Procedures
224 Q0083 Cancer Chemotherapy
224 Q0084 Cancer Chemotherapy
224 Q0085 Cancer Chemotherapy
234 Q0091 Pathology
226 Q0092 Other Diagnostic Radiology And Related Techniques
234 Q0111 Pathology
206 Q0112 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
206 Q0113 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
138 Q0114 Diagnostic Amniocentesis
206 Q0115 Microscopic Examination (Bacterial Smear, Culture, Toxicology)
240 Q0138 Medications (Injections, infusions and other forms)
240 Q0139 Medications (Injections, infusions and other forms)
240 Q0144 Medications (Injections, infusions and other forms)
240 Q0161 Medications (Injections, infusions and other forms)
240 Q0162 Medications (Injections, infusions and other forms)
240 Q0163 Medications (Injections, infusions and other forms)
240 Q0164 Medications (Injections, infusions and other forms)
240 Q0166 Medications (Injections, infusions and other forms)
240 Q0167 Medications (Injections, infusions and other forms)
240 Q0169 Medications (Injections, infusions and other forms)
240 Q0173 Medications (Injections, infusions and other forms)
240 Q0174 Medications (Injections, infusions and other forms)
240 Q0175 Medications (Injections, infusions and other forms)
240 Q0177 Medications (Injections, infusions and other forms)
240 Q0180 Medications (Injections, infusions and other forms)
240 Q0181 Medications (Injections, infusions and other forms)
243V Q0477 DME and supplies-Vendor
243V Q0478 DME and supplies-Vendor
243V Q0479 DME and supplies-Vendor
243V Q0480 DME and supplies-Vendor
243V Q0481 DME and supplies-Vendor
243V Q0482 DME and supplies-Vendor
243V Q0483 DME and supplies-Vendor
243V Q0484 DME and supplies-Vendor
243V Q0485 DME and supplies-Vendor
243V Q0486 DME and supplies-Vendor
243V Q0487 DME and supplies-Vendor
243V Q0488 DME and supplies-Vendor
243V Q0489 DME and supplies-Vendor
243V Q0490 DME and supplies-Vendor
243V Q0491 DME and supplies-Vendor
243V Q0492 DME and supplies-Vendor
243V Q0493 DME and supplies-Vendor
243V Q0494 DME and supplies-Vendor
243V Q0495 DME and supplies-Vendor
243V Q0496 DME and supplies-Vendor
243V Q0497 DME and supplies-Vendor
243V Q0498 DME and supplies-Vendor
243V Q0499 DME and supplies-Vendor
243V Q0500 DME and supplies-Vendor
243V Q0501 DME and supplies-Vendor
243V Q0502 DME and supplies-Vendor
243V Q0503 DME and supplies-Vendor
243V Q0504 DME and supplies-Vendor
243V Q0506 DME and supplies-Vendor
243V Q0507 DME and supplies-Vendor
243V Q0508 DME and supplies-Vendor
243V Q0509 DME and supplies-Vendor
240 Q0510 Medications (Injections, infusions and other forms)
240 Q0511 Medications (Injections, infusions and other forms)
240 Q0512 Medications (Injections, infusions and other forms)
240 Q0513 Medications (Injections, infusions and other forms)
240 Q0514 Medications (Injections, infusions and other forms)
240 Q0515 Medications (Injections, infusions and other forms)
Blue Cross NC Proprietary and Confidential 190 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
241 Q1004 Visual Aids And Other Optical Supplies
241 Q1005 Visual Aids And Other Optical Supplies
240 Q2004 Medications (Injections, infusions and other forms)
240 Q2009 Medications (Injections, infusions and other forms)
240 Q2017 Medications (Injections, infusions and other forms)
240 Q2026 Medications (Injections, infusions and other forms)
240 Q2028 Medications (Injections, infusions and other forms)
240 Q2033 Medications (Injections, infusions and other forms)
240 Q2034 Medications (Injections, infusions and other forms)
240 Q2035 Medications (Injections, infusions and other forms)
240 Q2036 Medications (Injections, infusions and other forms)
240 Q2037 Medications (Injections, infusions and other forms)
240 Q2038 Medications (Injections, infusions and other forms)
240 Q2039 Medications (Injections, infusions and other forms)
240 Q2041 Medications (Injections, infusions and other forms)
240 Q2042 Medications (Injections, infusions and other forms)
240 Q2043 Medications (Injections, infusions and other forms)
240 Q2049 Medications (Injections, infusions and other forms)
240 Q2050 Medications (Injections, infusions and other forms)
240 Q2052 Medications (Injections, infusions and other forms)
243V Q3001 DME and supplies-Vendor
237 Q3014 Ancillary Services
240 Q3027 Medications (Injections, infusions and other forms)
240 Q3028 Medications (Injections, infusions and other forms)
235 Q3031 Other Laboratory
243 Q4001 DME and supplies
243 Q4002 DME and supplies
243 Q4003 DME and supplies
243 Q4004 DME and supplies
243 Q4005 DME and supplies
243 Q4006 DME and supplies
243 Q4007 DME and supplies
243 Q4008 DME and supplies
243 Q4009 DME and supplies
243 Q4010 DME and supplies
243 Q4011 DME and supplies
243 Q4012 DME and supplies
243 Q4013 DME and supplies
243 Q4014 DME and supplies
243 Q4015 DME and supplies
243 Q4016 DME and supplies
243 Q4017 DME and supplies
243 Q4018 DME and supplies
243 Q4019 DME and supplies
243 Q4020 DME and supplies
243 Q4021 DME and supplies
243 Q4022 DME and supplies
243 Q4023 DME and supplies
243 Q4024 DME and supplies
243 Q4025 DME and supplies
243 Q4026 DME and supplies
243 Q4027 DME and supplies
243 Q4028 DME and supplies
243 Q4029 DME and supplies
243 Q4030 DME and supplies
243 Q4031 DME and supplies
243 Q4032 DME and supplies
243 Q4033 DME and supplies
243 Q4034 DME and supplies
243 Q4035 DME and supplies
243 Q4036 DME and supplies
243 Q4037 DME and supplies
243 Q4038 DME and supplies
243 Q4039 DME and supplies
243 Q4040 DME and supplies
243 Q4041 DME and supplies
243 Q4042 DME and supplies
243 Q4043 DME and supplies
243 Q4044 DME and supplies
243 Q4045 DME and supplies
243 Q4046 DME and supplies
243 Q4047 DME and supplies
243 Q4048 DME and supplies
243 Q4049 DME and supplies
Blue Cross NC Proprietary and Confidential 191 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
243 Q4050 DME and supplies
243 Q4051 DME and supplies
240 Q4074 Medications (Injections, infusions and other forms)
240 Q4081 Medications (Injections, infusions and other forms)
240 Q4082 Medications (Injections, infusions and other forms)
243 Q4100 DME and supplies
243 Q4101 DME and supplies
243 Q4102 DME and supplies
243 Q4103 DME and supplies
243 Q4104 DME and supplies
243 Q4105 DME and supplies
243 Q4106 DME and supplies
243 Q4107 DME and supplies
243 Q4108 DME and supplies
243 Q4110 DME and supplies
243 Q4111 DME and supplies
243 Q4112 DME and supplies
243 Q4113 DME and supplies
243 Q4114 DME and supplies
243 Q4115 DME and supplies
243 Q4116 DME and supplies
243 Q4117 DME and supplies
243 Q4118 DME and supplies
243 Q4121 DME and supplies
243 Q4122 DME and supplies
243 Q4123 DME and supplies
243 Q4124 DME and supplies
243 Q4125 DME and supplies
243 Q4126 DME and supplies
243 Q4127 DME and supplies
243 Q4128 DME and supplies
243 Q4130 DME and supplies
243 Q4132 DME and supplies
243 Q4133 DME and supplies
243 Q4134 DME and supplies
243 Q4135 DME and supplies
243 Q4136 DME and supplies
243 Q4137 DME and supplies
243 Q4138 DME and supplies
243 Q4139 DME and supplies
243 Q4140 DME and supplies
243 Q4141 DME and supplies
243 Q4142 DME and supplies
243 Q4143 DME and supplies
243 Q4145 DME and supplies
243 Q4146 DME and supplies
243 Q4147 DME and supplies
243 Q4148 DME and supplies
243 Q4149 DME and supplies
243 Q4150 DME and supplies
243 Q4151 DME and supplies
243 Q4152 DME and supplies
243 Q4153 DME and supplies
243 Q4154 DME and supplies
243 Q4155 DME and supplies
243 Q4156 DME and supplies
243 Q4157 DME and supplies
243 Q4158 DME and supplies
243 Q4159 DME and supplies
243 Q4160 DME and supplies
243 Q4161 DME and supplies
243 Q4162 DME and supplies
243 Q4163 DME and supplies
243 Q4164 DME and supplies
243 Q4165 DME and supplies
243 Q4166 DME and supplies
243 Q4167 DME and supplies
243 Q4168 DME and supplies
243 Q4169 DME and supplies
243 Q4170 DME and supplies
243 Q4171 DME and supplies
243 Q4173 DME and supplies
243 Q4174 DME and supplies
243 Q4175 DME and supplies
Blue Cross NC Proprietary and Confidential 192 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
243 Q4176 DME and supplies
243 Q4177 DME and supplies
243 Q4178 DME and supplies
243 Q4179 DME and supplies
243 Q4180 DME and supplies
243 Q4181 DME and supplies
243 Q4182 DME and supplies
243 Q4183 DME and supplies
243 Q4184 DME and supplies
243 Q4185 DME and supplies
243 Q4186 DME and supplies
243 Q4187 DME and supplies
243 Q4188 DME and supplies
243 Q4189 DME and supplies
243 Q4190 DME and supplies
243 Q4191 DME and supplies
243 Q4192 DME and supplies
243 Q4193 DME and supplies
243 Q4194 DME and supplies
243 Q4195 DME and supplies
243 Q4196 DME and supplies
243 Q4197 DME and supplies
243 Q4198 DME and supplies
243 Q4200 DME and supplies
243 Q4201 DME and supplies
243 Q4202 DME and supplies
243 Q4203 DME and supplies
243 Q4204 DME and supplies
243 Q4205 DME and supplies
243 Q4206 DME and supplies
243 Q4208 DME and supplies
243 Q4209 DME and supplies
243 Q4210 DME and supplies
243 Q4211 DME and supplies
243 Q4212 DME and supplies
243 Q4213 DME and supplies
243 Q4214 DME and supplies
243 Q4215 DME and supplies
243 Q4216 DME and supplies
243 Q4217 DME and supplies
243 Q4218 DME and supplies
243 Q4219 DME and supplies
243 Q4220 DME and supplies
243 Q4221 DME and supplies
243 Q4222 DME and supplies
243 Q4226 DME and supplies
231 Q5001 Other Therapeutic Procedures
231 Q5002 Other Therapeutic Procedures
231 Q5003 Other Therapeutic Procedures
231 Q5004 Other Therapeutic Procedures
231 Q5005 Other Therapeutic Procedures
231 Q5006 Other Therapeutic Procedures
231 Q5007 Other Therapeutic Procedures
231 Q5008 Other Therapeutic Procedures
231 Q5009 Other Therapeutic Procedures
240 Q5101 Medications (Injections, infusions and other forms)
240 Q5103 Medications (Injections, infusions and other forms)
240 Q5104 Medications (Injections, infusions and other forms)
240 Q5107 Medications (Injections, infusions and other forms)
240 Q5109 Medications (Injections, infusions and other forms)
240 Q5111 Medications (Injections, infusions and other forms)
240 Q5112 Medications (Injections, infusions and other forms)
240 Q5113 Medications (Injections, infusions and other forms)
240 Q5114 Medications (Injections, infusions and other forms)
240 Q5115 Medications (Injections, infusions and other forms)
240 Q5116 Medications (Injections, infusions and other forms)
240 Q5117 Medications (Injections, infusions and other forms)
240 Q5118 Medications (Injections, infusions and other forms)
240 Q9950 Medications (Injections, infusions and other forms)
243V Q9951 DME and supplies-Vendor
240 Q9953 Medications (Injections, infusions and other forms)
243V Q9954 DME and supplies-Vendor
240 Q9955 Medications (Injections, infusions and other forms)
240 Q9956 Medications (Injections, infusions and other forms)
Blue Cross NC Proprietary and Confidential 193 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
240 Q9957 Medications (Injections, infusions and other forms)
243V Q9958 DME and supplies-Vendor
243V Q9959 DME and supplies-Vendor
243V Q9960 DME and supplies-Vendor
243V Q9961 DME and supplies-Vendor
243V Q9962 DME and supplies-Vendor
243V Q9963 DME and supplies-Vendor
243V Q9964 DME and supplies-Vendor
243V Q9965 DME and supplies-Vendor
243V Q9966 DME and supplies-Vendor
243V Q9967 DME and supplies-Vendor
243V Q9968 DME and supplies-Vendor
243V Q9969 DME and supplies-Vendor
243V Q9982 DME and supplies-Vendor
243V Q9983 DME and supplies-Vendor
239 R0070 Transportation - Patient, Provider, Equipment
239 R0075 Transportation - Patient, Provider, Equipment
239 R0076 Transportation - Patient, Provider, Equipment
240 S0012 Medications (Injections, infusions and other forms)
240 S0014 Medications (Injections, infusions and other forms)
240 S0017 Medications (Injections, infusions and other forms)
240 S0020 Medications (Injections, infusions and other forms)
240 S0021 Medications (Injections, infusions and other forms)
240 S0023 Medications (Injections, infusions and other forms)
240 S0028 Medications (Injections, infusions and other forms)
240 S0030 Medications (Injections, infusions and other forms)
240 S0032 Medications (Injections, infusions and other forms)
240 S0034 Medications (Injections, infusions and other forms)
240 S0039 Medications (Injections, infusions and other forms)
240 S0040 Medications (Injections, infusions and other forms)
240 S0073 Medications (Injections, infusions and other forms)
240 S0074 Medications (Injections, infusions and other forms)
240 S0077 Medications (Injections, infusions and other forms)
240 S0078 Medications (Injections, infusions and other forms)
240 S0080 Medications (Injections, infusions and other forms)
240 S0081 Medications (Injections, infusions and other forms)
240 S0088 Medications (Injections, infusions and other forms)
240 S0090 Medications (Injections, infusions and other forms)
240 S0091 Medications (Injections, infusions and other forms)
240 S0092 Medications (Injections, infusions and other forms)
240 S0093 Medications (Injections, infusions and other forms)
240 S0104 Medications (Injections, infusions and other forms)
240 S0106 Medications (Injections, infusions and other forms)
240 S0108 Medications (Injections, infusions and other forms)
240 S0109 Medications (Injections, infusions and other forms)
240 S0117 Medications (Injections, infusions and other forms)
240 S0119 Medications (Injections, infusions and other forms)
240 S0122 Medications (Injections, infusions and other forms)
240 S0126 Medications (Injections, infusions and other forms)
240 S0128 Medications (Injections, infusions and other forms)
240 S0132 Medications (Injections, infusions and other forms)
240 S0136 Medications (Injections, infusions and other forms)
240 S0137 Medications (Injections, infusions and other forms)
240 S0138 Medications (Injections, infusions and other forms)
240 S0139 Medications (Injections, infusions and other forms)
240 S0140 Medications (Injections, infusions and other forms)
240 S0142 Medications (Injections, infusions and other forms)
240 S0145 Medications (Injections, infusions and other forms)
240 S0148 Medications (Injections, infusions and other forms)
243 S0155 DME and supplies
240 S0156 Medications (Injections, infusions and other forms)
240 S0157 Medications (Injections, infusions and other forms)
240 S0160 Medications (Injections, infusions and other forms)
240 S0164 Medications (Injections, infusions and other forms)
240 S0166 Medications (Injections, infusions and other forms)
240 S0169 Medications (Injections, infusions and other forms)
240 S0170 Medications (Injections, infusions and other forms)
240 S0171 Medications (Injections, infusions and other forms)
240 S0172 Medications (Injections, infusions and other forms)
240 S0174 Medications (Injections, infusions and other forms)
240 S0175 Medications (Injections, infusions and other forms)
240 S0176 Medications (Injections, infusions and other forms)
240 S0177 Medications (Injections, infusions and other forms)
240 S0178 Medications (Injections, infusions and other forms)
Blue Cross NC Proprietary and Confidential 194 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
240 S0179 Medications (Injections, infusions and other forms)
240 S0182 Medications (Injections, infusions and other forms)
240 S0183 Medications (Injections, infusions and other forms)
240 S0187 Medications (Injections, infusions and other forms)
240 S0189 Medications (Injections, infusions and other forms)
240 S0190 Medications (Injections, infusions and other forms)
240 S0191 Medications (Injections, infusions and other forms)
240 S0194 Medications (Injections, infusions and other forms)
240 S0197 Medications (Injections, infusions and other forms)
126 S0199 Abortion (Termination Of Pregnancy)
218 S0201 Psychological And Psychiatric Evaluation And Therapy
237 S0207 Ancillary Services
237 S0208 Ancillary Services
239 S0209 Transportation - Patient, Provider, Equipment
239 S0215 Transportation - Patient, Provider, Equipment
237 S0220 Ancillary Services
237 S0221 Ancillary Services
237 S0250 Ancillary Services
237 S0255 Ancillary Services
237 S0257 Ancillary Services
227 S0260 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
237 S0265 Ancillary Services
236 S0270 Home Health Services
236 S0271 Home Health Services
236 S0272 Home Health Services
236 S0273 Home Health Services
236 S0274 Home Health Services
237 S0280 Ancillary Services
237 S0281 Ancillary Services
227 S0302 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
237 S0310 Ancillary Services
237 S0311 Ancillary Services
237 S0315 Ancillary Services
237 S0316 Ancillary Services
237 S0317 Ancillary Services
237 S0320 Ancillary Services
237 S0340 Ancillary Services
237 S0341 Ancillary Services
237 S0342 Ancillary Services
227 S0353 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 S0354 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
174 S0390 Other Non-Or Therapeutic Procedures On Skin And Breast
237 S0395 Ancillary Services
107 S0400 Extracorporeal Lithotripsy, Urinary
241 S0500 Visual Aids And Other Optical Supplies
241 S0504 Visual Aids And Other Optical Supplies
241 S0506 Visual Aids And Other Optical Supplies
241 S0508 Visual Aids And Other Optical Supplies
241 S0510 Visual Aids And Other Optical Supplies
241 S0512 Visual Aids And Other Optical Supplies
241 S0514 Visual Aids And Other Optical Supplies
241 S0515 Visual Aids And Other Optical Supplies
241 S0516 Visual Aids And Other Optical Supplies
241 S0518 Visual Aids And Other Optical Supplies
241 S0580 Visual Aids And Other Optical Supplies
241 S0581 Visual Aids And Other Optical Supplies
241 S0590 Visual Aids And Other Optical Supplies
241 S0592 Visual Aids And Other Optical Supplies
241 S0595 Visual Aids And Other Optical Supplies
241 S0596 Visual Aids And Other Optical Supplies
77 S0601 Proctoscopy And Anorectal Biopsy
M1A S0610 Office Visits - New
M1B S0612 Office Visits - Established
227 S0613 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
220 S0618 Ophthalmologic And Otologic Diagnosis And Treatment
CEC S0620 Ophthalmologic And Otologic Diagnosis And Treatment
CEC S0621 Ophthalmologic And Otologic Diagnosis And Treatment
227 S0622 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
231 S0630 Other Therapeutic Procedures
19 S0800 Ophthalmologic And Otologic Diagnosis And Treatment
19 S0810 Ophthalmologic And Otologic Diagnosis And Treatment
19 S0812 Ophthalmologic And Otologic Diagnosis And Treatment
243 S1001 DME and supplies
243 S1002 DME and supplies
Blue Cross NC Proprietary and Confidential 195 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
243 S1015 DME and supplies
243 S1016 DME and supplies
243 S1030 DME and supplies
243 S1031 DME and supplies
243 S1034 DME and supplies
243 S1035 DME and supplies
243 S1036 DME and supplies
243 S1037 DME and supplies
243V S1040 DME and supplies-Vendor
240 S1090 Medications (Injections, infusions and other forms)
176 S2053 Other Organ Transplantation
176 S2054 Other Organ Transplantation
176 S2055 Other Organ Transplantation
176 S2060 Other Organ Transplantation
36 S2061 Lobectomy Or Pneumonectomy
105 S2065 Kidney Transplant
175 S2066 Other Or Therapeutic Procedures On Skin And Breast
174 S2067 Other Non-Or Therapeutic Procedures On Skin And Breast
175 S2068 Other Or Therapeutic Procedures On Skin And Breast
101 S2070 Transurethral Excision, Drainage, Or Removal Urinary Obstruction
94 S2079 Other Or Upper GI Therapeutic Procedures
33 S2080 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
93 S2083 Other Non-Or Upper GI Therapeutic Procedures
54 S2095 Other Vascular Catheterization, Not Heart
176 S2102 Other Organ Transplantation
176 S2103 Other Organ Transplantation
224 S2107 Cancer Chemotherapy
149 S2112 Arthroscopy
162 S2115 Other Or Therapeutic Procedures On Joints
154 S2117 Arthroplasty Other Than Hip Or Knee
153 S2118 Hip Replacement, Total And Partial
233 S2120 Laboratory - Chemistry And Hematology
64 S2140 Bone Marrow Transplant
222 S2142 Blood Transfusion
233 S2150 Laboratory - Chemistry And Hematology
176 S2152 Other Organ Transplantation
231 S2202 Other Therapeutic Procedures
44 S2205 Coronary Artery Bypass Graft (CABG)
44 S2206 Coronary Artery Bypass Graft (CABG)
44 S2207 Coronary Artery Bypass Graft (CABG)
44 S2208 Coronary Artery Bypass Graft (CABG)
44 S2209 Coronary Artery Bypass Graft (CABG)
23 S2225 Myringotomy
25 S2230 Diagnostic Procedures On Ear
9 S2235 Other Or Therapeutic Nervous System Procedures
126 S2260 Abortion (Termination Of Pregnancy)
126 S2265 Abortion (Termination Of Pregnancy)
126 S2266 Abortion (Termination Of Pregnancy)
126 S2267 Abortion (Termination Of Pregnancy)
149 S2300 Arthroscopy
162 S2325 Other Or Therapeutic Procedures On Joints
42 S2340 Other Or Therapeutic Procedures On Respiratory System
42 S2341 Other Or Therapeutic Procedures On Respiratory System
33 S2342 Other Or Therapeutic Procedures On Nose, Mouth And Pharynx
3 S2348 Laminectomy, Excision Intervertebral Disc
3 S2350 Laminectomy, Excision Intervertebral Disc
3 S2351 Laminectomy, Excision Intervertebral Disc
141 S2400 Other Therapeutic Obstetrical Procedures
141 S2401 Other Therapeutic Obstetrical Procedures
141 S2402 Other Therapeutic Obstetrical Procedures
141 S2403 Other Therapeutic Obstetrical Procedures
141 S2404 Other Therapeutic Obstetrical Procedures
141 S2405 Other Therapeutic Obstetrical Procedures
141 S2409 Other Therapeutic Obstetrical Procedures
141 S2411 Other Therapeutic Obstetrical Procedures
237 S2900 Ancillary Services
18 S3000 Diagnostic Procedures On Eye
237 S3005 Ancillary Services
243 S3600 DME and supplies
236 S3601 Home Health Services
233 S3620 Laboratory - Chemistry And Hematology
233 S3630 Laboratory - Chemistry And Hematology
235 S3645 Other Laboratory
235 S3650 Other Laboratory
Blue Cross NC Proprietary and Confidential 196 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
235 S3652 Other Laboratory
233 S3655 Laboratory - Chemistry And Hematology
235 S3708 Other Laboratory
235 S3722 Other Laboratory
235 S3800 Other Laboratory
235 S3840 Other Laboratory
235 S3841 Other Laboratory
235 S3842 Other Laboratory
235 S3844 Other Laboratory
235 S3845 Other Laboratory
235 S3846 Other Laboratory
235 S3849 Other Laboratory
235 S3850 Other Laboratory
235 S3852 Other Laboratory
235 S3853 Other Laboratory
235 S3854 Other Laboratory
235 S3861 Other Laboratory
235 S3865 Other Laboratory
235 S3866 Other Laboratory
235 S3870 Other Laboratory
7 S3900 Other Diagnostic Nervous System Procedures
62 S3902 Other Diagnostic Cardiovascular Procedures
201 S3904 Cardiac Stress Tests
141 S4005 Other Therapeutic Obstetrical Procedures
238 S4011 Infertility Services
238 S4013 Infertility Services
238 S4014 Infertility Services
238 S4015 Infertility Services
238 S4016 Infertility Services
238 S4017 Infertility Services
238 S4018 Infertility Services
238 S4020 Infertility Services
238 S4021 Infertility Services
238 S4022 Infertility Services
238 S4023 Infertility Services
238 S4025 Infertility Services
238 S4026 Infertility Services
235 S4027 Other Laboratory
238 S4028 Infertility Services
235 S4030 Other Laboratory
235 S4031 Other Laboratory
238 S4035 Infertility Services
238 S4037 Infertility Services
238 S4040 Infertility Services
238 S4042 Infertility Services
141 S4981 Other Therapeutic Obstetrical Procedures
243 S4989 DME and supplies
240 S4990 Medications (Injections, infusions and other forms)
240 S4991 Medications (Injections, infusions and other forms)
240 S4993 Medications (Injections, infusions and other forms)
240 S4995 Medications (Injections, infusions and other forms)
240 S5000 Medications (Injections, infusions and other forms)
240 S5001 Medications (Injections, infusions and other forms)
243 S5010 DME and supplies
240 S5012 Medications (Injections, infusions and other forms)
243 S5013 DME and supplies
240 S5014 Medications (Injections, infusions and other forms)
236 S5035 Home Health Services
236 S5036 Home Health Services
237 S5100 Ancillary Services
237 S5101 Ancillary Services
237 S5102 Ancillary Services
237 S5105 Ancillary Services
236 S5108 Home Health Services
236 S5109 Home Health Services
236 S5110 Home Health Services
236 S5111 Home Health Services
236 S5115 Home Health Services
236 S5116 Home Health Services
236 S5120 Home Health Services
236 S5121 Home Health Services
236 S5125 Home Health Services
236 S5126 Home Health Services
236 S5130 Home Health Services
Blue Cross NC Proprietary and Confidential 197 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
236 S5131 Home Health Services
236 S5135 Home Health Services
236 S5136 Home Health Services
237 S5140 Ancillary Services
237 S5141 Ancillary Services
237 S5145 Ancillary Services
237 S5146 Ancillary Services
237 S5150 Ancillary Services
237 S5151 Ancillary Services
243 S5160 DME and supplies
243 S5161 DME and supplies
243 S5162 DME and supplies
243 S5165 DME and supplies
236 S5170 Home Health Services
236 S5175 Home Health Services
236 S5180 Home Health Services
236 S5181 Home Health Services
236 S5185 Home Health Services
227 S5190 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
243 S5199 DME and supplies
236 S5497 Home Health Services
236 S5498 Home Health Services
236 S5501 Home Health Services
236 S5502 Home Health Services
236 S5517 Home Health Services
236 S5518 Home Health Services
236 S5520 Home Health Services
236 S5521 Home Health Services
236 S5522 Home Health Services
236 S5523 Home Health Services
240 S5550 Medications (Injections, infusions and other forms)
240 S5551 Medications (Injections, infusions and other forms)
240 S5552 Medications (Injections, infusions and other forms)
240 S5553 Medications (Injections, infusions and other forms)
243 S5560 DME and supplies
243 S5561 DME and supplies
243 S5565 DME and supplies
243 S5566 DME and supplies
243 S5570 DME and supplies
243 S5571 DME and supplies
211 S8030 Therapeutic Radiology
198 S8035 Magnetic Resonance Imaging
198 S8037 Magnetic Resonance Imaging
7 S8040 Other Diagnostic Nervous System Procedures
198 S8042 Magnetic Resonance Imaging
126 S8055 Abortion (Termination Of Pregnancy)
182 S8080 Mammography
209 S8085 Radioisotope Scan And Function Studies
180 S8092 Other CT Scan
243 S8096 DME and supplies
243 S8097 DME and supplies
243 S8100 DME and supplies
243 S8101 DME and supplies
243 S8110 DME and supplies
243V S8120 DME and supplies-Vendor
243V S8121 DME and supplies-Vendor
243V S8130 DME and supplies-Vendor
243V S8131 DME and supplies-Vendor
243 S8185 DME and supplies
243 S8186 DME and supplies
243 S8189 DME and supplies
243 S8210 DME and supplies
243 S8265 DME and supplies
243 S8270 DME and supplies
243 S8301 DME and supplies
243 S8415 DME and supplies
243 S8420 DME and supplies
243 S8421 DME and supplies
243 S8422 DME and supplies
243 S8423 DME and supplies
243 S8424 DME and supplies
243 S8425 DME and supplies
243 S8426 DME and supplies
243 S8427 DME and supplies
Blue Cross NC Proprietary and Confidential 198 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
243 S8428 DME and supplies
243 S8429 DME and supplies
243 S8430 DME and supplies
243 S8431 DME and supplies
243 S8450 DME and supplies
243 S8451 DME and supplies
243 S8452 DME and supplies
243V S8460 DME and supplies-Vendor
243 S8490 DME and supplies
213 S8930 Physical Therapy Exercises, Manipulation, And Other Procedures
213 S8940 Physical Therapy Exercises, Manipulation, And Other Procedures
231 S8948 Other Therapeutic Procedures
213 S8950 Physical Therapy Exercises, Manipulation, And Other Procedures
213 S8990 Physical Therapy Exercises, Manipulation, And Other Procedures
243 S8999 DME and supplies
243 S9001 DME and supplies
243 S9007 DME and supplies
192 S9024 Diagnostic Ultrasound Of Head And Neck
202 S9025 Electrocardiogram
230 S9034 Extracorporeal Shock Wave, Other Than Urinary
243 S9055 DME and supplies
231 S9056 Other Therapeutic Procedures
236 S9061 Home Health Services
237 S9083 Ancillary Services
237 S9088 Ancillary Services
8 S9090 Other Non-Or Or Closed Therapeutic Nervous System Procedures
236 S9097 Home Health Services
236 S9098 Home Health Services
227 S9110 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
227 S9117 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
236 S9122 Home Health Services
236 S9123 Home Health Services
236 S9124 Home Health Services
236 S9125 Home Health Services
236 S9126 Home Health Services
237 S9127 Ancillary Services
236 S9128 Home Health Services
236 S9129 Home Health Services
236 S9131 Home Health Services
M1B S9140 Office Visits - Established
M1B S9141 Office Visits - Established
237 S9145 Ancillary Services
241 S9150 Visual Aids And Other Optical Supplies
213 S9152 Physical Therapy Exercises, Manipulation, And Other Procedures
236 S9208 Home Health Services
236 S9209 Home Health Services
236 S9211 Home Health Services
236 S9212 Home Health Services
236 S9213 Home Health Services
236 S9214 Home Health Services
236 S9325 Home Health Services
236 S9326 Home Health Services
236 S9327 Home Health Services
236 S9328 Home Health Services
236 S9329 Home Health Services
236 S9330 Home Health Services
236 S9331 Home Health Services
236 S9335 Home Health Services
236 S9336 Home Health Services
236 S9338 Home Health Services
236 S9339 Home Health Services
236 S9340 Home Health Services
236 S9341 Home Health Services
236 S9342 Home Health Services
236 S9343 Home Health Services
236 S9345 Home Health Services
236 S9346 Home Health Services
236 S9347 Home Health Services
236 S9348 Home Health Services
236 S9349 Home Health Services
236 S9351 Home Health Services
236 S9353 Home Health Services
236 S9355 Home Health Services
236 S9357 Home Health Services
Blue Cross NC Proprietary and Confidential 199 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
236 S9359 Home Health Services
236 S9361 Home Health Services
236 S9363 Home Health Services
236 S9364 Home Health Services
236 S9365 Home Health Services
236 S9366 Home Health Services
236 S9367 Home Health Services
236 S9368 Home Health Services
236 S9370 Home Health Services
236 S9372 Home Health Services
236 S9373 Home Health Services
236 S9374 Home Health Services
236 S9375 Home Health Services
236 S9376 Home Health Services
236 S9377 Home Health Services
236 S9379 Home Health Services
239 S9381 Transportation - Patient, Provider, Equipment
237 S9401 Ancillary Services
237 S9430 Ancillary Services
243 S9433 DME and supplies
243 S9434 DME and supplies
243 S9435 DME and supplies
237 S9436 Ancillary Services
237 S9437 Ancillary Services
237 S9438 Ancillary Services
237 S9439 Ancillary Services
237 S9441 Ancillary Services
237 S9442 Ancillary Services
237 S9443 Ancillary Services
237 S9444 Ancillary Services
237 S9445 Ancillary Services
237 S9446 Ancillary Services
237 S9447 Ancillary Services
237 S9449 Ancillary Services
237 S9451 Ancillary Services
237 S9452 Ancillary Services
237 S9453 Ancillary Services
237 S9454 Ancillary Services
237 S9455 Ancillary Services
M1B S9460 Office Visits - Established
237 S9465 Ancillary Services
237 S9470 Ancillary Services
213 S9472 Physical Therapy Exercises, Manipulation, And Other Procedures
213 S9473 Physical Therapy Exercises, Manipulation, And Other Procedures
231 S9474 Other Therapeutic Procedures
219 S9475 Alcohol And Drug Rehabilitation/Detoxification
213 S9476 Physical Therapy Exercises, Manipulation, And Other Procedures
218 S9480 Psychological And Psychiatric Evaluation And Therapy
218 S9482 Psychological And Psychiatric Evaluation And Therapy
218 S9484 Psychological And Psychiatric Evaluation And Therapy
218 S9485 Psychological And Psychiatric Evaluation And Therapy
236 S9490 Home Health Services
236 S9494 Home Health Services
236 S9497 Home Health Services
236 S9500 Home Health Services
236 S9501 Home Health Services
236 S9502 Home Health Services
236 S9503 Home Health Services
236 S9504 Home Health Services
235 S9529 Other Laboratory
236 S9537 Home Health Services
236 S9538 Home Health Services
236 S9542 Home Health Services
236 S9558 Home Health Services
236 S9559 Home Health Services
236 S9560 Home Health Services
236 S9562 Home Health Services
236 S9590 Home Health Services
236 S9810 Home Health Services
237 S9900 Ancillary Services
237 S9901 Ancillary Services
239 S9960 Transportation - Patient, Provider, Equipment
239 S9961 Transportation - Patient, Provider, Equipment
237 S9970 Ancillary Services
Blue Cross NC Proprietary and Confidential 200 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
239 S9975 Transportation - Patient, Provider, Equipment
237 S9976 Ancillary Services
237 S9977 Ancillary Services
237 S9981 Ancillary Services
237 S9982 Ancillary Services
237 S9986 Ancillary Services
237 S9988 Ancillary Services
237 S9989 Ancillary Services
237 S9990 Ancillary Services
237 S9991 Ancillary Services
239 S9992 Transportation - Patient, Provider, Equipment
237 S9994 Ancillary Services
237 S9996 Ancillary Services
237 S9999 Ancillary Services
237 T1000 Ancillary Services
237 T1001 Ancillary Services
237 T1002 Ancillary Services
237 T1003 Ancillary Services
237 T1004 Ancillary Services
219 T1006 Alcohol And Drug Rehabilitation/Detoxification
219 T1007 Alcohol And Drug Rehabilitation/Detoxification
219 T1009 Alcohol And Drug Rehabilitation/Detoxification
219 T1010 Alcohol And Drug Rehabilitation/Detoxification
219 T1012 Alcohol And Drug Rehabilitation/Detoxification
237 T1013 Ancillary Services
237 T1014 Ancillary Services
227 T1015 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
237 T1016 Ancillary Services
237 T1017 Ancillary Services
237 T1018 Ancillary Services
236 T1019 Home Health Services
236 T1020 Home Health Services
236 T1021 Home Health Services
236 T1022 Home Health Services
237 T1023 Ancillary Services
237 T1024 Ancillary Services
237 T1025 Ancillary Services
237 T1026 Ancillary Services
237 T1027 Ancillary Services
236 T1028 Home Health Services
236 T1029 Home Health Services
236 T1030 Home Health Services
236 T1031 Home Health Services
218 T1040 Psychological And Psychiatric Evaluation And Therapy
218 T1041 Psychological And Psychiatric Evaluation And Therapy
236 T1502 Home Health Services
236 T1503 Home Health Services
243 T1999 DME and supplies
239 T2001 Transportation - Patient, Provider, Equipment
239 T2002 Transportation - Patient, Provider, Equipment
239 T2003 Transportation - Patient, Provider, Equipment
239 T2004 Transportation - Patient, Provider, Equipment
239 T2005 Transportation - Patient, Provider, Equipment
239 T2007 Transportation - Patient, Provider, Equipment
237 T2010 Ancillary Services
237 T2011 Ancillary Services
237 T2012 Ancillary Services
237 T2013 Ancillary Services
237 T2014 Ancillary Services
237 T2015 Ancillary Services
237 T2016 Ancillary Services
237 T2017 Ancillary Services
237 T2018 Ancillary Services
237 T2019 Ancillary Services
237 T2020 Ancillary Services
237 T2021 Ancillary Services
237 T2022 Ancillary Services
237 T2023 Ancillary Services
237 T2024 Ancillary Services
237 T2025 Ancillary Services
237 T2026 Ancillary Services
237 T2027 Ancillary Services
243 T2028 DME and supplies
243V T2029 DME and supplies-Vendor
Blue Cross NC Proprietary and Confidential 201 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
237 T2030 Ancillary Services
237 T2031 Ancillary Services
237 T2032 Ancillary Services
237 T2033 Ancillary Services
237 T2034 Ancillary Services
237 T2035 Ancillary Services
237 T2036 Ancillary Services
237 T2037 Ancillary Services
237 T2038 Ancillary Services
243V T2039 DME and supplies-Vendor
237 T2040 Ancillary Services
237 T2041 Ancillary Services
236 T2042 Home Health Services
236 T2043 Home Health Services
237 T2044 Ancillary Services
237 T2045 Ancillary Services
237 T2046 Ancillary Services
218 T2048 Psychological And Psychiatric Evaluation And Therapy
239 T2049 Transportation - Patient, Provider, Equipment
243V T2101 DME and supplies-Vendor
243V T4521 DME and supplies-Vendor
243V T4522 DME and supplies-Vendor
243V T4523 DME and supplies-Vendor
243V T4524 DME and supplies-Vendor
243V T4525 DME and supplies-Vendor
243V T4526 DME and supplies-Vendor
243V T4527 DME and supplies-Vendor
243V T4528 DME and supplies-Vendor
243V T4529 DME and supplies-Vendor
243V T4530 DME and supplies-Vendor
243V T4531 DME and supplies-Vendor
243V T4532 DME and supplies-Vendor
243V T4533 DME and supplies-Vendor
243V T4534 DME and supplies-Vendor
243V T4535 DME and supplies-Vendor
243V T4536 DME and supplies-Vendor
243V T4537 DME and supplies-Vendor
243V T4538 DME and supplies-Vendor
243V T4539 DME and supplies-Vendor
243V T4540 DME and supplies-Vendor
243V T4541 DME and supplies-Vendor
243V T4542 DME and supplies-Vendor
243V T4543 DME and supplies-Vendor
243V T4544 DME and supplies-Vendor
243V T4545 DME and supplies-Vendor
243V T5001 DME and supplies-Vendor
243V T5999 DME and supplies-Vendor
234 U0001 Pathology
234 U0002 Pathology
234 U0003 Pathology
234 U0004 Pathology
241 V2020 Visual Aids And Other Optical Supplies
241 V2025 Visual Aids And Other Optical Supplies
241 V2100 Visual Aids And Other Optical Supplies
241 V2101 Visual Aids And Other Optical Supplies
241 V2102 Visual Aids And Other Optical Supplies
241 V2103 Visual Aids And Other Optical Supplies
241 V2104 Visual Aids And Other Optical Supplies
241 V2105 Visual Aids And Other Optical Supplies
241 V2106 Visual Aids And Other Optical Supplies
241 V2107 Visual Aids And Other Optical Supplies
241 V2108 Visual Aids And Other Optical Supplies
241 V2109 Visual Aids And Other Optical Supplies
241 V2110 Visual Aids And Other Optical Supplies
241 V2111 Visual Aids And Other Optical Supplies
241 V2112 Visual Aids And Other Optical Supplies
241 V2113 Visual Aids And Other Optical Supplies
241 V2114 Visual Aids And Other Optical Supplies
241 V2115 Visual Aids And Other Optical Supplies
241 V2118 Visual Aids And Other Optical Supplies
241 V2121 Visual Aids And Other Optical Supplies
241 V2199 Visual Aids And Other Optical Supplies
241 V2200 Visual Aids And Other Optical Supplies
241 V2201 Visual Aids And Other Optical Supplies
Blue Cross NC Proprietary and Confidential 202 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
241 V2202 Visual Aids And Other Optical Supplies
241 V2203 Visual Aids And Other Optical Supplies
241 V2204 Visual Aids And Other Optical Supplies
241 V2205 Visual Aids And Other Optical Supplies
241 V2206 Visual Aids And Other Optical Supplies
241 V2207 Visual Aids And Other Optical Supplies
241 V2208 Visual Aids And Other Optical Supplies
241 V2209 Visual Aids And Other Optical Supplies
241 V2210 Visual Aids And Other Optical Supplies
241 V2211 Visual Aids And Other Optical Supplies
241 V2212 Visual Aids And Other Optical Supplies
241 V2213 Visual Aids And Other Optical Supplies
241 V2214 Visual Aids And Other Optical Supplies
241 V2215 Visual Aids And Other Optical Supplies
241 V2218 Visual Aids And Other Optical Supplies
241 V2219 Visual Aids And Other Optical Supplies
241 V2220 Visual Aids And Other Optical Supplies
241 V2221 Visual Aids And Other Optical Supplies
241 V2299 Visual Aids And Other Optical Supplies
241 V2300 Visual Aids And Other Optical Supplies
241 V2301 Visual Aids And Other Optical Supplies
241 V2302 Visual Aids And Other Optical Supplies
241 V2303 Visual Aids And Other Optical Supplies
241 V2304 Visual Aids And Other Optical Supplies
241 V2305 Visual Aids And Other Optical Supplies
241 V2306 Visual Aids And Other Optical Supplies
241 V2307 Visual Aids And Other Optical Supplies
241 V2308 Visual Aids And Other Optical Supplies
241 V2309 Visual Aids And Other Optical Supplies
241 V2310 Visual Aids And Other Optical Supplies
241 V2311 Visual Aids And Other Optical Supplies
241 V2312 Visual Aids And Other Optical Supplies
241 V2313 Visual Aids And Other Optical Supplies
241 V2314 Visual Aids And Other Optical Supplies
241 V2315 Visual Aids And Other Optical Supplies
241 V2318 Visual Aids And Other Optical Supplies
241 V2319 Visual Aids And Other Optical Supplies
241 V2320 Visual Aids And Other Optical Supplies
241 V2321 Visual Aids And Other Optical Supplies
241 V2399 Visual Aids And Other Optical Supplies
241 V2410 Visual Aids And Other Optical Supplies
241 V2430 Visual Aids And Other Optical Supplies
241 V2499 Visual Aids And Other Optical Supplies
241 V2500 Visual Aids And Other Optical Supplies
241 V2501 Visual Aids And Other Optical Supplies
241 V2502 Visual Aids And Other Optical Supplies
241 V2503 Visual Aids And Other Optical Supplies
241 V2510 Visual Aids And Other Optical Supplies
241 V2511 Visual Aids And Other Optical Supplies
241 V2512 Visual Aids And Other Optical Supplies
241 V2513 Visual Aids And Other Optical Supplies
241 V2520 Visual Aids And Other Optical Supplies
241 V2521 Visual Aids And Other Optical Supplies
241 V2522 Visual Aids And Other Optical Supplies
241 V2523 Visual Aids And Other Optical Supplies
241 V2530 Visual Aids And Other Optical Supplies
241 V2531 Visual Aids And Other Optical Supplies
241 V2599 Visual Aids And Other Optical Supplies
241 V2600 Visual Aids And Other Optical Supplies
241 V2610 Visual Aids And Other Optical Supplies
241 V2615 Visual Aids And Other Optical Supplies
241 V2623 Visual Aids And Other Optical Supplies
241 V2624 Visual Aids And Other Optical Supplies
241 V2625 Visual Aids And Other Optical Supplies
241 V2626 Visual Aids And Other Optical Supplies
241 V2627 Visual Aids And Other Optical Supplies
241 V2628 Visual Aids And Other Optical Supplies
241 V2629 Visual Aids And Other Optical Supplies
241 V2630 Visual Aids And Other Optical Supplies
241 V2631 Visual Aids And Other Optical Supplies
241 V2632 Visual Aids And Other Optical Supplies
241 V2700 Visual Aids And Other Optical Supplies
241 V2702 Visual Aids And Other Optical Supplies
241 V2710 Visual Aids And Other Optical Supplies
Blue Cross NC Proprietary and Confidential 203 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
241 V2715 Visual Aids And Other Optical Supplies
241 V2718 Visual Aids And Other Optical Supplies
241 V2730 Visual Aids And Other Optical Supplies
241 V2744 Visual Aids And Other Optical Supplies
241 V2745 Visual Aids And Other Optical Supplies
241 V2750 Visual Aids And Other Optical Supplies
241 V2755 Visual Aids And Other Optical Supplies
241 V2756 Visual Aids And Other Optical Supplies
241 V2760 Visual Aids And Other Optical Supplies
241 V2761 Visual Aids And Other Optical Supplies
241 V2762 Visual Aids And Other Optical Supplies
241 V2770 Visual Aids And Other Optical Supplies
241 V2780 Visual Aids And Other Optical Supplies
241 V2781 Visual Aids And Other Optical Supplies
241 V2782 Visual Aids And Other Optical Supplies
241 V2783 Visual Aids And Other Optical Supplies
241 V2784 Visual Aids And Other Optical Supplies
241 V2785 Visual Aids And Other Optical Supplies
241 V2786 Visual Aids And Other Optical Supplies
241 V2787 Visual Aids And Other Optical Supplies
241 V2788 Visual Aids And Other Optical Supplies
241 V2790 Visual Aids And Other Optical Supplies
241 V2797 Visual Aids And Other Optical Supplies
241 V2799 Visual Aids And Other Optical Supplies
220 V5008 Ophthalmologic And Otologic Diagnosis And Treatment
220 V5010 Ophthalmologic And Otologic Diagnosis And Treatment
242 V5011 Hearing devices and audiology supplies
242 V5014 Hearing devices and audiology supplies
220 V5020 Ophthalmologic And Otologic Diagnosis And Treatment
242 V5030 Hearing devices and audiology supplies
242 V5040 Hearing devices and audiology supplies
242 V5050 Hearing devices and audiology supplies
242 V5060 Hearing devices and audiology supplies
242 V5070 Hearing devices and audiology supplies
242 V5080 Hearing devices and audiology supplies
242 V5090 Hearing devices and audiology supplies
242 V5095 Hearing devices and audiology supplies
242 V5100 Hearing devices and audiology supplies
242 V5110 Hearing devices and audiology supplies
242 V5120 Hearing devices and audiology supplies
242 V5130 Hearing devices and audiology supplies
242 V5140 Hearing devices and audiology supplies
242 V5150 Hearing devices and audiology supplies
242 V5160 Hearing devices and audiology supplies
242 V5171 Hearing devices and audiology supplies
242 V5172 Hearing devices and audiology supplies
242 V5181 Hearing devices and audiology supplies
242 V5190 Hearing devices and audiology supplies
242 V5200 Hearing devices and audiology supplies
242 V5211 Hearing devices and audiology supplies
242 V5212 Hearing devices and audiology supplies
242 V5213 Hearing devices and audiology supplies
242 V5214 Hearing devices and audiology supplies
242 V5215 Hearing devices and audiology supplies
242 V5221 Hearing devices and audiology supplies
242 V5230 Hearing devices and audiology supplies
242 V5240 Hearing devices and audiology supplies
242 V5241 Hearing devices and audiology supplies
242 V5242 Hearing devices and audiology supplies
242 V5243 Hearing devices and audiology supplies
242 V5244 Hearing devices and audiology supplies
242 V5245 Hearing devices and audiology supplies
242 V5246 Hearing devices and audiology supplies
242 V5247 Hearing devices and audiology supplies
242 V5248 Hearing devices and audiology supplies
242 V5249 Hearing devices and audiology supplies
242 V5250 Hearing devices and audiology supplies
242 V5251 Hearing devices and audiology supplies
242 V5252 Hearing devices and audiology supplies
242 V5253 Hearing devices and audiology supplies
242 V5254 Hearing devices and audiology supplies
242 V5255 Hearing devices and audiology supplies
242 V5256 Hearing devices and audiology supplies
242 V5257 Hearing devices and audiology supplies
Blue Cross NC Proprietary and Confidential 204 of 205
CCS/BETOS Fee Schedule
Category and Code Listing by Service Code
Effective April 1, 2020
CCS/BETOS Category Service Code CCS_BETOS Description
242 V5258 Hearing devices and audiology supplies
242 V5259 Hearing devices and audiology supplies
242 V5260 Hearing devices and audiology supplies
242 V5261 Hearing devices and audiology supplies
242 V5262 Hearing devices and audiology supplies
242 V5263 Hearing devices and audiology supplies
242 V5264 Hearing devices and audiology supplies
242 V5265 Hearing devices and audiology supplies
242 V5266 Hearing devices and audiology supplies
242 V5267 Hearing devices and audiology supplies
242 V5268 Hearing devices and audiology supplies
242 V5269 Hearing devices and audiology supplies
242 V5270 Hearing devices and audiology supplies
242 V5271 Hearing devices and audiology supplies
242 V5272 Hearing devices and audiology supplies
242 V5273 Hearing devices and audiology supplies
242 V5274 Hearing devices and audiology supplies
242 V5275 Hearing devices and audiology supplies
242 V5281 Hearing devices and audiology supplies
242 V5282 Hearing devices and audiology supplies
242 V5283 Hearing devices and audiology supplies
242 V5284 Hearing devices and audiology supplies
242 V5285 Hearing devices and audiology supplies
242 V5286 Hearing devices and audiology supplies
242 V5287 Hearing devices and audiology supplies
242 V5288 Hearing devices and audiology supplies
242 V5289 Hearing devices and audiology supplies
242 V5290 Hearing devices and audiology supplies
242 V5298 Hearing devices and audiology supplies
242 V5299 Hearing devices and audiology supplies
242 V5336 Hearing devices and audiology supplies
215 V5362 Other Physical Therapy And Rehabilitation
215 V5363 Other Physical Therapy And Rehabilitation
227 V5364 Other Diagnostic Procedures (Interview, Evaluation, Consultation)
Blue Cross NC Proprietary and Confidential 205 of 205
