Provider Fee Schedule Request

 
Email *
Professional *
Provider Name *
Tax Identification Number *
Office Manager *
Phone Number *
Fax Number
Allied Health Provider? *
For every CPT/CDT Code entered below, the corresponding Billed Charge MUST be provided. Any requests missing the Billed Charge for a CPT/CDT Code, cannot be accepted.

If your request includes more than 20 codes, please call (260) 266-5520.
1. CPT/CDT Code
Modifier(s)
Billed Charge
2. CPT/CDT Code
Modifier(s)
Billed Charge
3. CPT/CDT Code
Modifier(s)
Billed Charge
4. CPT/CDT Code
Modifier(s)
Billed Charge
5. CPT/CDT Code
Modifier(s)
Billed Charge
6. CPT/CDT Code
Modifier(s)
Billed Charge
7. CPT/CDT Code
Modifier(s)
Billed Charge
8. CPT/CDT Code
Modifier(s)
Billed Charge
9. CPT/CDT Code
Modifier(s)
Billed Charge
10. CPT/CDT Code
Modifier(s)
Billed Charge
11. CPT/CDT Code
Modifier(s)
Billed Charge
12. CPT/CDT Code
Modifier(s)
Billed Charge
13. CPT/CDT Code
Modifier(s)
Billed Charge
14. CPT/CDT Code
Modifier(s)
Billed Charge
15. CPT/CDT Code
Modifier(s)
Billed Charge
16. CPT/CDT Code
Modifier(s)
Billed Charge
17. CPT/CDT Code
Modifier(s)
Billed Charge
18. CPT/CDT Code
Modifier(s)
Billed Charge
19. CPT/CDT Code
Modifier(s)
Billed Charge
20. CPT/CDT Code
Modifier(s)
Billed Charge