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STAT, Please Call
ROUTINE
DISPATCH : 623-257-1399
FAX ORDER TO: 623-257-2133
patient information
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Address/Facility:
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client information:
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insurance
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Medicare #
Medicaid #
Other Insurance
ID #
GRP #
Responsible Party Name/Address/Phone
Reason for Portable Exam
ICD 10 Diagnostic Codes
Procedures Ordered
chest/abdomen
Rib, Bilateral, 3V
71110
Chest AP
71045
Rib, 2V
L
R
71100
Chest AP & Lat
71046
Abdomen, 1V
74018
Abdomen, 2V
74019
Abdomen, 3V
74021
spine & pelvis
T-Spine, 2V
72070
Pelvis, АР only
72170
Cervical, 2V ог 3V
72040
Lumbrosacral, 2V
72100
Thoraco Lumbar 2V
72080
Sacroiliac
72200
head & neck
Sinuses, paranasal: < 3V
72210
Skull 4 views
72260
Facial Bones, < 3V
70140
Nasal Bones, 3+V
70160
lower extremities
Foot:2V
L
R
73620
Toe(s), 2+V
L
R
73660
Femur, 2V
L
R
73552
Knee, 1V or 2V
L
R
73560
Tibla & Fibula, 2V
L
R
73590
Ankle,2V
L
R
73600
Hip, Unil: 1V
L
R
73501
Hip, Complete: 2V
L
R
73502
upper extremities
Elbow, 2V
L
R
73070
Forearm, 2V
L
R
73090
Shoulder, 2+V
L
R
73090
Humerus 2+V
L
R
73060
Clavicle, complete
L
R
73000
Shoulder, 1V
L
R
73020
Wrist, 2V
L
R
73100
Hand, 2V
L
R
73120
Finger(s), 2+V
L
R
73140
ultrasound
US Pelvis (non-OB)
76856
US Scrotum
76870
US Testical
93975
US Carotid
93880
US Retroperitoneal
76770
US Ext Non Vascular
L
R
76882
US ОВ Pregnant Uterus
76805
US Thyroid/Neck
76536
US Breast
L
R
76641
US Chest
76604
US Abdominal
76700
Ankle/Brachial lndex
93922
US Vascular Retroperitoneal
93975
Segmental Pressures Low Ext
93923
US Arterial LE
L
R
93925
US Arterial UE
L
R
93930
US Venous LE
L
R
93970
US Venous UE
L
R
93970
electrocardiogram
EKG
93000
echocardiogram
Echocardiogram
93306
other exam