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J~ <br />BCBSNC Fee Schedule Disclosure <br />Orange County EMS <br />Code Fee <br />A0425 $6 .29 <br />A0426 $223 .97 <br />A0427 $354 .64 <br />A0428 $186 .65 <br />A0429 $298 .63 <br />A0432 $326 .63 <br />A0433 $513 .28 <br />A0434 $606 .60 <br />A0435 $7 .56 <br />A0436 $20.14 <br />03019 $298 .63 <br />03020 $186 .65 <br />Orange County Charges as of May 17, 2005 <br />Mileage $6.00 <br />Advanced Life Support 1 (ALS1) $425.00 <br />Basic Life Support 1 (BLS1) $325.00 <br />Advanced Life Support 2 (ALS2) $500.00 <br />AO0999 Non Transport Treatment is not a covered cost therefore <br />Orange County can bill full amount and collect. <br />Labs, HCPCS, and therapy codes are based on the BCBSNC statewide fee schedule <br />Claims are paid at the lesser of charge or fee schedule <br />I accept the reimbursement as indicated above. <br />Provider's Signature: <br />Aate: <br />05/12/2005 <br />