Provider Name

45078
23423
JohnSmith

APPROVE

Access HealthNet
     105 W. Michigan St.
     10th Floor
     Milwaukee, WI 53203
414 249 5755
414 249 5759

CPT DESCRIPTION CHARGE WC CHARGE
ADD ROW
Net Bundle Total $0.00 $250.00
Admin Fee $0.00 $15.96
WC Facilitation $0.00 $54.88
Gross Bundle Total $0.00 $320.84
Save   Delete  

CPT DESCRIPTION CHARGE
ADD ROW
Save   Delete  
Net Bundle Total $1,400
AHN Admin Fee $100
Gross Bundle Total $1,500
CPT DESCRIPTION CHARGE
ADD ROW
Save   Delete  
Net Bundle Total $1,400
AHN Admin Fee $100
Gross Bundle Total $1,500