Fee Schedule Request – Center Care

All fields with an asterisk (*) MUST be completed

Provider Information
Group/Organization Name*
Tax ID Number (TIN)*
Provider Name(s)*
NPI Last Name First Name Middle Initial Degree
Request Information
Code List*
Code Modifier Per Unit Billed Charge
Upload File
Max. file size: 20 MB.
If you have a spreadsheet of codes for which you are requesting allowables, please upload the file here.
Contact Information
Contact Name*
First Last
Contact Address*
Address Line 1 Address Line 2 City State ZIP Code
Contact Phone*
Contact Email*
Name
This field is for validation purposes and should be left unchanged.

NPI	Last Name	First Name	Middle Initial	Degree

Code	Modifier	Per Unit Billed Charge

Provider Information