Wiki Billing BCBS for ASC

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I am new to BCBS ASC faciclity billing and want to make sure I am doing it correctly...can someone tell me how this example would look on a UB-04 claim please...

14301, 1 unit, $1000 per unit
14302, 2 units, $450 per unit
15200, 1 unit, $1200 per unit

Thank you! I have only billed for Medicare and they use the CMS-1500.
 
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