Fee Schedule Request

All fields with an asterisk (*) MUST be completed

Provider Name(s)*

NPI	Last Name	First Name	Middle Initial	Degree

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.

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Provider Information