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