Survey of Charges Orthodontists - ODS Health Plans 2026

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  1. Click ‘Get Form’ to open it in the editor.
  2. Begin by entering your name and license number at the top of the form. This personal information is essential for identification.
  3. Fill in your office address, city, TIN number, telephone, and fax details. Ensure accuracy as this information is crucial for communication.
  4. Proceed to the charges section. For each procedure code listed (e.g., D0150, D8020), enter your corresponding fees in the provided spaces.
  5. If applicable, add any additional codes and their respective fees in the designated areas at the bottom of each section.
  6. Finally, review all entries for accuracy. Sign and date the form to certify that these are the fees you intend to charge your patients.

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