Contact Information Center Name* Contact Name* Mailing Address* Email Address* Phone Number* Center Information Number of Location(s) Total Number of Rooms(s) Number of Days the Rooms(s) are Open per Week Total Number of Patient Procedures Done Annually Average Number of Minutes per Case Payor Mix for Total Cases In-Network Case Percentage checked Aetna % checked UHC % checked BCBS % checked Cigna % checked Humana % checked Medicaid % checked Medicare % checked Medicaid HMO % checked Medicare HMO % checked Self Pay % checked Other % Total should equal 100% Total 0 % Top 10 CPT Codes CPT # Annually 1) 2) 3) 4) 5) 6) 7) 8) 9) 10) Items marked with * are required.
