| 1 | Medical Care |
| 2 | Surgical |
| 3 | Consultation |
| 4 | Diagnostic X-Ray |
| 5 | Diagnostic Lab |
| 6 | Radiation Therapy |
| 7 | Anesthesia |
| 8 | Surgical Assistance |
| 9 | Other Medical |
| 10 | Blood Charges |
| 11 | Used Durable Medical Equipment |
| 12 | Durable Medical Equipment Purchase |
| 13 | Ambulatory Service Center Facility |
| 14 | Renal Supplies in the Home |
| 15 | Alternate Method Dialysis |
| 16 | Chronic Renal Disease (CRD) Equipment |
| 17 | Pre-Admission Testing |
| 18 | Durable Medical Equipment Rental |
| 19 | Pneumonia Vaccine |
| 20 | Second Surgical Opinion |
| 21 | Third Surgical Opinion |
| 22 | Social Work |
| 23 | Diagnostic Dental |
| 24 | Periodontics |
| 25 | Restorative |
| 26 | Endodontics |
| 27 | Maxillofacial Prosthetics |
| 28 | Adjunctive Dental Services |
| 30 | Health Benefit Plan Coverage |
| 31 | Benefit Disclaimer |
| 32 | Plan Waiting Period |
| 33 | Chiropractic |
| 34 | Chiropractic Office Visits |
| 35 | Dental Care |
| 36 | Dental Crowns |
| 37 | Dental Accident |
| 38 | Orthodontics |
| 39 | Prosthodontics |
| 40 | Oral Surgery |
| 41 | Routine (Preventive) Dental |
| 42 | Home Health Care |
| 43 | Home Health Prescriptions |
| 44 | Home Health Visits |
| 45 | Hospice |
| 46 | Respite Care |
| 47 | Hospital |
| 48 | Hospital - Inpatient |
| 49 | Hospital - Room and Board |
| 50 | Hospital - Outpatient |
| 51 | Hospital - Emergency Accident |
| 52 | Hospital - Emergency Medical |
| 53 | Hospital - Ambulatory Surgical |
| 54 | Long Term Care |
| 55 | Major Medical |
| 56 | Medically Related Transportation |
| 57 | Air Transportation |
| 58 | Cabulance |
| 59 | Licensed Ambulance |
| 60 | General Benefits |
| 61 | In-vitro Fertilization |
| 62 | MRI/CAT Scan |
| 63 | Donor Procedures |
| 64 | Acupuncture |
| 65 | Newborn Care |
| 66 | Pathology |
| 67 | Smoking Cessation |
| 68 | Well Baby Care |
| 69 | Maternity |
| 70 | Transplants |
| 71 | Audiology Exam |
| 72 | Inhalation Therapy |
| 73 | Diagnostic Medical |
| 74 | Private Duty Nursing |
| 75 | Prosthetic Device |
| 76 | Dialysis |
| 77 | Otological Exam |
| 78 | Chemotherapy |
| 79 | Allergy Testing |
| 80 | Immunizations |
| 81 | Routine Physical |
| 82 | Family Planning |
| 83 | Infertility |
| 84 | Abortion |
| 85 | AIDS |
| 86 | Emergency Services |
| 87 | Cancer |
| 88 | Pharmacy |
| 89 | Free Standing Prescription Drug |
| 90 | Mail Order Prescription Drug |
| 91 | Brand Name Prescription Drug |
| 92 | Generic Prescription Drug |
| 93 | Podiatry |
| 94 | Podiatry - Office Visits |
| 95 | Podiatry - Nursing Home Visits |
| 96 | Professional (Physician) |
| 97 | Anesthesiologist |
| 98 | Professional (Physician) Visit - Office |
| 99 | Professional (Physician) Visit - Inpatient |
| A0 | Professional (Physician) Visit - Outpatient |
| A1 | Professional (Physician) Visit - Nursing Home |
| A2 | Professional (Physician) Visit - Skilled Nursing Facility |
| A3 | Professional (Physician) Visit - Home |
| A4 | Psychiatric |
| A5 | Psychiatric - Room and Board |
| A6 | Psychotherapy |
| A7 | Psychiatric - Inpatient |
| A8 | Psychiatric - Outpatient |
| A9 | Rehabilitation |
| AA | Rehabilitation - Room and Board |
| AB | Rehabilitation - Inpatient |
| AC | Rehabilitation - Outpatient |
| AD | Occupational Therapy |
| AE | Physical Medicine |
| AF | Speech Therapy |
| AG | Skilled Nursing Care |
| AH | Skilled Nursing Care - Room and Board |
| AI | Substance Abuse |
| AJ | Alcoholism |
| AK | Drug Addiction |
| AL | Vision (Optometry) |
| AM | Frames |
| AN | Routine Exam |
| AO | Lenses |
| AP | Routine Eye Exam |
| AQ | Nonmedically Necessary Physical These physicals are required by other entities e.g., insurance application, pilot license, employment or school |
| AR | Experimental Drug Therapy |
| B | Non-escrow or Non-impound Service |
| B1 | Burn Care |
| B2 | Brand Name Prescription Drug - Formulary |
| B3 | Brand Name Prescription Drug - Non-Formulary |
| BA | Independent Medical Evaluation |
| BB | Partial Hospitalization (Psychiatric) |
| BC | Day Care (Psychiatric) |
| BD | Cognitive Therapy |
| BE | Massage Therapy |
| BF | Pulmonary Rehabilitation |
| BG | Cardiac Rehabilitation |
| BH | Pediatric |
| BI | Nursery |
| BJ | Skin |
| BK | Orthopedic |
| BL | Cardiac |
| BM | Lymphatic |
| BN | Gastrointestinal |
| BP | Endocrine |
| BQ | Neurology |
| BR | Eye |
| BS | Invasive Procedures |
| BT | Gynecological |
| BU | Obstetrical |
| BV | Obstetrical/Gynecological |
| BW | Mail Order Prescription Drug: Brand Name |
| BX | Mail Order Prescription Drug: Generic |
| BY | Physician Visit - Office: Sick |
| BZ | Physician Visit - Office: Well |
| C | Escrow or Impound Service |
| C1 | Coronary Care |
| CA | Private Duty Nursing - Inpatient |
| CB | Private Duty Nursing - Home |
| CC | Surgical Benefits - Professional (Physician) |
| CD | Surgical Benefits - Facility |
| CE | Mental Health Provider - Inpatient |
| CF | Mental Health Provider - Outpatient |
| CG | Mental Health Facility - Inpatient |
| CH | Mental Health Facility - Outpatient |
| CI | Substance Abuse Facility - Inpatient |
| CJ | Substance Abuse Facility - Outpatient |
| CK | Screening X-ray |
| CL | Screening laboratory |
| CM | Mammogram, High Risk Patient |
| CN | Mammogram, Low Risk Patient |
| CO | Flu Vaccination |
| CP | Eyewear and Eyewear Accessories |
| CQ | Case Management |
| DG | Dermatology |
| DM | Durable Medical Equipment |
| DS | Diabetic Supplies |
| GF | Generic Prescription Drug - Formulary |
| GN | Generic Prescription Drug - Non-Formulary |
| GY | Allergy |
| IC | Intensive Care |
| MH | Mental Health |
| NI | Neonatal Intensive Care |
| ON | Oncology |
| PT | Physical Therapy |
| PU | Pulmonary |
| RN | Renal |
| RT | Residential Psychiatric Treatment |
| TC | Transitional Care |
| TN | Transitional Nursery Care |
| UC | Urgent Care |