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APPT DATE:
ARRIVAL TIME:
PATIENT NAME:
SS#:
SEX:
MALE
FEMALE
DOB:
DRUG ALLERGIES:
DIAGNOSIS:
PHYSICIAN SIGNATURE:
STAT
SEND FILMS WITH PATIENT
DELIVER FILM & REPORT WITHIN 24 HRS
CALL PATIENT TO SCHEDULE DIAGNOSTIC TEST
COMMENTS:
MRI
Abdomen
74181
Abdomen w/wo Contrast
74183
Brain
70551
Brain w/wo Contrast
70553
Cervical Spine w/wo Contrast
72156
Lower Extremity
73718
Specify Area:
Lower Extremity Joint
73721
Specify Area:
Lumbar
72148
Lumbar w/wo Contrast
72158
MRA Abdomen
74185
MRA Brain
70544
MRA Neck
70547
MRA Lower Extremity
73725
Specify Area:
MRA Upper Extremity
73225
Specify Area:
Orbit/Face/Neck
70540
Orbit/Face/Neck w/wo Contrast
70543
Pelvis
72195
Pelvis w/wo Contrast
72197
Temporomandibular Joint
70336
Thoracic Spine
72146
Thoracic Spine w/wo Contrast
72157
Upper Extremity
73218
Specify Area:
Upper Extremity Joint
73221
Specify Area:
MRI ARTHROGRAM (specify left or right)
Ankle
Left
Right
Elbow
Left
Right
Hip
Left
Right
Shoulder
Left
Right
Wrist
Left
Right
ULTRASOUND
Abdomen Complete
76700
Gallbladder or Liver
76705
Renal
76775
Arterial Lwr Ext Bilateral
93925
Arterial Lwr Ext Unilateral
93926
Arterial Upper Ext Bilateral
93930
Arterial Upper Ext Unilateral
93931
Breast(s)
76645
Carotids
93880
Extremity Non Vascular
76880
Specify Area:
Extremity Venous Bilateral
93970
Exermity Venous Unilateral
93971
OB First Trimester Single Gestation
76801
OB After First Trimester Single Gestation
76805
Pelvic
76856
Testicular
76870
Thyroid
76536
Transvaginal
76830
Echo Cardiography
93307
CT
Abdomen
74150
Abdomen w/wo Contrast
74170
Brain
70450
Brain w/wo Contrast
70470
Cervical Spine
72125
Chest
71250
Chest With Contrast
71260
Lower Extremity
73700
Specify Area:
Lumbar
72131
Neck Soft Tissue w/wo Contrast
70490
Orbit/Sella/Posterior Fossa
70480
Outer, Middle, Inner Ear
70480
Pelvis
72192
Pelvis With Contrast
72193
Sinus
70486
Screening Sinus
70486
Thoracic Spine
72128
Upper Extremity
73200
Specify Area:
CT MYELOGRAM
Cervical Spine
Lumbar Spine
Thoracic Spine
XRAY PROCEDURES REQUESTED:
OTHER PROCEDURES REQUESTED:
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