Fee Schedule Request

All fields with an asterisk (*) MUST be completed

  • Provider Information

  • NPILast NameFirst NameMiddle InitialDegree 
  • Request Information

  • CodeModifierPer Unit Billed Charge 
  • If you have a spreadsheet of codes for which you are requesting allowables, please upload the file here.
  • Contact Information

  • This field is for validation purposes and should be left unchanged.