Request Phoenix Print Blank Form Please provide necessary information to perform exam. Additional documents can be faxed to 602.787.9729 Patient Information * Facility Name / Room # Date of Service ... * Patient Full Name * Date of Birth ... * Sex SELECT PATIENT SEX MALE FEMALE * Physical Address * Patient Phone Number Patient Social Security # Guarantor / Guardian / Responsible Party Information Full Name Contact Phone # Patient Insurance Information Primary Insurance Program Primary Insurance # Secondary Insurance Program Secondary Insurance # Clinical Information * Exam Requested PLEASE SELECT AN EXAM ABDOMEN, AP - 74000 ABDOMEN, COMPLETE - 74020 ABDOMEN, MULTI VIEWS - 74010 AC JOINTS - 73050 ANKLE, AP & LAT (L) - 73560 ANKLE, AP & LAT (R) - 73560 ANKLE, COMPLETE (L) - 73610 ANKLE, COMPLETE (R) - 73610 BLE, ARTERIAL - 93925 BLE, VENOUS - 93970 BUE, ARTERIAL - 93925 BUE, VENOUS - 93970 BONE AGE STUDIES (L) - 77072 BONE AGE STUDIES (R) - 77072 BONE SURVEY, COMPLETE - 77075 CHEST, DECUBITUS - 71035 CHEST, LORODOTIC - 71021 CHEST, OBLIQUE (L) - 71022 CHEST, OBLIQUE (R) - 71022 CHEST, PA & LAT - 71020 CHEST, SINGLE VIEW - 71010 CLAVICLE, COMPLETE - 73000 DUP SCAN/AORTAL/INF VENA CAV LILIAC VASCULATURE OR BYPASS GRAFTS COMPLETE - 93978 DUP SCAN/AORTAL/INF VENA CAV LILIAC VASCULATURE OR BYPASS GRAFTS LIMITED - 93979 DUP SCAN/ARTERIAL INFLOW & OUTFLOW OF ABDOMINAL, PELVIS & RETROPERITONEAL (RENAL) ORGANS, COMPLETE - 93975 DUP SCAN/EXTRACRANIAL ARTERY COMPLETE BILATERAL STUDY - 93880 DUP SCAN/EXTRACRANIAL ARTERY FOLLOW UP OR LIMITED STUDY - 93882 ECHO EXTREMITY, NON-VASCULAR - 76881 ECHO, ABDOMINAL COMPLETE - 76700 ECHO, ABDOMINAL LIMITED - 76705 ECHO, BRACHIAL ARTERY BILATERAL - 93923 ECHO, BRACHIAL ARTERY UNILATERAL - 93922 ECHO, BREAST COMPLETE - 76641 ECHO, BREAST COMPLETE - 76642 ECHOCARDIOGRAM - 93306 ECHO, PALVIA (NON OB) - 76856 ECHO, RETROPERITONEAL (RENAL) COMPLETE - 76770 ECHO, RETROPERITONEAL (RENAL) LIMITED - 76775 ECHO, SCROTUM & CONCEPTS - 76870 ECHO, SOFT TISSUE, HEAD/NECK THYROID - 76536 EKG/ECG - 93000 ELBOW, 4AP & LAT (L) - 73070 ELBOW, 4AP & LAT (R) - 73070 ELBOW, COMPLETE (L) - 73080 ELBOW, COMPLETE (R) - 73080 ENTIRE SCOLIOSIS STUDY - 72010 EYES, FOREIGN BODY - 70030 FACIAL BONES, COMPLETE - 70150 FACIAL BONES, LIMITED - 70140 FEMUR (L) - 73550 FEMUR (R) - 73550 FINGER/FINGERS (L) - 73140 FINGER/FINGERS (R) - 73140 FOOT, AP & LAT (L) - 73620 FOOT, AP & LAT (R) - 73620 FOOT, COMPLETE (L) - 73630 FOOT, COMPLETE (R) - 73630 FOREARM, AP & LAT (L) - 73090 FOREARM, AP & LAT (R) - 73090 HAND, AP & LAT (L) - 73120 HAND, AP & LAT (R) - 73120 HAND, COMPLETE (L) - 73130 HAND, COMPLETE (R) - 73130 HEEL CALCANEUS (L) - 73650 HEEL CALCANEUS (R) - 73650 HIP, UNILATERAL COMPLETE (L) - 73510 HIP, UNILATERAL COMPLETE (R) - 73510 HIPS, BILATERAL - 73520 HIPS, INFANT/CHILD - 73540 HUMERUS (L) - 73060 HUMERUS (R) - 73060 KNEE, 3 VIEW (L) - 73562 KNEE, 3 VIEW (R) - 73562 KNEE, AP & LAT (L) - 73560 KNEE, AP & LAT (R) - 73560 KNEE, COMPLETE (L) - 73564 KNEE, COMPLETE (R) - 73564 KNEES, BILATERAL STANDING (L) - 73565 KNEES, BILATERAL STANDING (R) - 73565 LLE, ARTERIAL - 93926 LLE, VENOUS - 93971 LUE, ARTERIAL - 93926 LUE, VENOUS - 93971 LUMBAR BEND 6 MIN VIEW - 72114 MANDIBLE, COMPLETE - 70110 MANDIBLE, LIMITED - 70100 MASTIODS, COMPLETE - 70130 MASTIODS, LIMITED - 70120 NASAL BONES, COMPLETE - 70160 ORBITS, COMPETE - 70200 OSSEOUS SURVEY - 77074 PELVIS, 3 VIEW - 72190 PELVIS, AP ONLY - 72170 PELVIS, LIMITED (BLADDER) - 76857 RIBS 4 VIEW PA CHEST - 71111 RIBS, 3 VIEW PA CHEST - 71101 RIBS, BILATERAL - 71110 RIBS, UNILATERAL (L) - 71100 RIBS, UNILATERAL (R) - 71100 RLE, ARTERIAL - 93926 RLE, VENOUS - 93971 RUE, ARTERIAL - 93926 RUE, VENOUS - 93971 SACRUM & COCCYX - 72220 SCAPULA (L) - 73010 SCAPULA (R) - 73010 SELLA, TURCICA - 70240 SHOULDER, COMPLETE (L) - 73030 SHOULDER, COMPLETE (R) - 73030 SHOULDER, PARTIAL (L) - 73020 SHOULDER, PARTIAL (R) - 73020 SI JOINTS, COMPLETE - 72202 SINUSES, COMPLETE - 70220 SINUSES, LIMITED - 70210 SKULL, COMPLETE - 70260 SKULL, LIMITED - 70250 SOFT TISSUE, NECK - 70360 SPINE, BENDING VIEWS - 72120 SPINE, CERVICAL 4 OR 5 VIEW - 72050 SPINE, CERVICAL AP & LAT - 72040 SPINE, CERVICAL COMPLETE - 72052 SPINE, LUMBAR AP & LAT - 72100 SPINE, LUMBAR COMPLETE - 72110 SPINE, SCOLIOSIS SURVEY - 72090 SPINE, THORACIC AP & LAT - 72070 SPINE, THORACIC COMPLETE - 72072 STERNOCLAVICULAR JOINTS - 71130 STERNUM - 71120 THORACOLUMBAR, AP & LAT - 72080 TIBIA/FIBULA (L) - 73590 TIBIA/FIBULA (R) - 73590 TMJ, BILATERAL - 70330 TMJ, OPEN & CLOSED - 70328 TMJ, UNILATERAL - 70320 TOES (L) - 73660 TOES (R) - 73660 WRIST, AP & LAT (L) - 73100 WRIST, AP & LAT (R) - 73100 WRIST, COMPLETE (L) - 73110 WRIST, COMPLETE (R) - 73110 * How Many Views * ICD-10 Code PLEASE SELECT AN ICD-10 CODE +PPD - R76.11 AAA W/O RUPTURE - I71.4 ABN CHEST SOUNDS - R09.89 ACUTE PULMONARY EDEMA - J81.0 ACUTE RESPIRATORY DISTRESS SYNDROME - J80 AFIB - I48.91 ANKLE PAIN (LEFT) - M25.572 ANKLE PAIN (RIGHT) - M25.571 BREAST LUMP - N63 CAD - I25.10 CAROTID BRUIT - R09.89 CHEST PAIN - R07.9 CHF - I50.9 CONGESTION - R06.89 COPD - J44.1 COUGH - R05 COUGH W/ HEMORRAGE - R04.89 DDD C SPINE - M50.30 DDD L SPINE - M51.36 DDD T SPINE - M51.34 DIZZINESS / GIDDINESS - R42 DVT (LEFT LOWER EXTREMITY) - I82.402 DVT (LEFT UPPER EXTREMITY) - I82.622 DVT (RIGHT LOWER EXTREMITY) - I82.401 DVT (RIGHT UPPER EXTREMITY) - I82.621 DYSPNEA - R06.09 EDEMA (GENERALIZED) - R60.1 EDEMA (LOCALIZED) - R60.0 ELBOW (LEFT) - M25.522 ELBOW (RIGHT) - M25.521 EPIGASTRIC - R10.13 FECAL IMPACTION - K56.49 FEMALE GENITAL SYMPTOMS - N94.89 FEVER - R50.9 FINGER PAIN (LEFT) - M79.645 FINGER PAIN (RIGHT) - M79.644 FOOT PAIN (LEFT) - M79.672 FOOT PAIN (RIGHT) - M79.671 FOREARM (LEFT) - M79.632 FOREARM (RIGHT) - M79.631 GASTROSTOMY ATTENTION ENCOUNTER - Z43.1 GASTROSTOMY STATUS - Z93.1 GENERAL - R10.84 GOITER - E04.2 HAND (LEFT) - M79.642 HAND (RIGHT) - M79.641 HIP PAIN (LEFT) - M25.552 HIP PAIN (RIGHT) - M25.551 KIDNEY CALCUNI - N20.0 KNEE PAIN (LEFT) - M25.562 KNEE PAIN (RIGHT) - M25.561 L SPINE - M54.5 NAUSEA - R11.0 NAUSEA W/ VOMITING - R11.2 OTHER CONSTIPATION - K59.09 OTHER NONSPECIFIC FINDINGS OF THE LUNG - R91.8 PAIN ABDOMINAL (LEFT LOWER QUADRANT) - R10.32 PAIN ABDOMINAL (LEFT UPPER QUADRANT) - R10.12 PAIN ABDOMINAL (RIGHT LOWER QUADRANT) - R10.31 PAIN ABDOMINAL (RIGHT UPPER QUADRANT) - R10.11 PAIN C SPINE - M54.2 PAIN IN LIMB (LEFT LOWER EXTREMITY) - M79.605 PAIN IN LIMB (LEFT UPPER EXTREMITY) - M79.602 PAIN IN LIMB (RIGHT LOWER EXTREMITY) - M79.604 PAIN IN LIMB (RIGHT UPPER EXTREMITY) - M79.601 PICC LINE - Z45.09 PNUEMONIA (SPECIFIED ORGANISM) - J16.8 PNUEMONIA (UNSPECIFIED ORGANISM) - J18.9 PPD (OTHER SPECIFIED PERIPHERAL VASCULAR DISEASE) - I73.89 PPD (UNSPECIFIED) - I73.9 PRECORDIAL PAIN - R07.2 PULMONARY FIBROSIS - J84.10 PULMONARY NODULE - R91.1 RESPIRATORY FAILURE - J96.00 RESPIRATORY FAILURE (CHRONIC) - J96.90 SHOULDER PAIN (LEFT) - M25.512 SHOULDER PAIN (RIGHT) - M25.511 SOB - R06.02 SOFT TISSUE NECK LUMP - R22.1 STENOSIS CAROTID ARTERY - I65.29 SWELLING LIMB (BILATERAL LOWER EXTREMITY) - R22.43 SWELLING LIMB (BILATERAL UPPER EXTREMITY) - R22.33 SWELLING LIMB (LEFT LOWER EXTREMITY) - R22.42 SWELLING LIMB (LEFT UPPER EXTREMITY) - R22.32 SWELLING LIMB (RIGHT LOWER EXTREMITY) - R22.41 SWELLING LIMB (RIGHT UPPER EXTREMITY) - R22.31 SWELLING MASS LUMP (CHEST) - R22.9 SWELLING MASS LUMP (TRUNK) - R22.2 T SPINE - M54.6 TB - A15.0 THIGH PAIN (LEFT) - M79.652 THIGH PAIN (RIGHT) - M79.651 THYROID NODULE - E04.1 TOES (LEFT) - M79.675 TOES (RIGHT) - M79.674 VASCULAR ACCESS DEVICE ADJUSTMENT/MANAGEMENT ENCOUNTER - Z45.2 VOMITING - R11.10 VOMITING (PROJECTILE) - R11.12 VOMITING W/O NAUSEA - R11.11 WHEEZING - R06.2 Exam Requested #2 PLEASE SELECT AN EXAM ABDOMEN, AP - 74000 ABDOMEN, COMPLETE - 74020 ABDOMEN, MULTI VIEWS - 74010 AC JOINTS - 73050 ANKLE, AP & LAT (L) - 73560 ANKLE, AP & LAT (R) - 73560 ANKLE, COMPLETE (L) - 73610 ANKLE, COMPLETE (R) - 73610 BLE, ARTERIAL - 93925 BLE, VENOUS - 93970 BUE, ARTERIAL - 93925 BUE, VENOUS - 93970 BONE AGE STUDIES (L) - 77072 BONE AGE STUDIES (R) - 77072 BONE SURVEY, COMPLETE - 77075 CHEST, DECUBITUS - 71035 CHEST, LORODOTIC - 71021 CHEST, OBLIQUE (L) - 71022 CHEST, OBLIQUE (R) - 71022 CHEST, PA & LAT - 71020 CHEST, SINGLE VIEW - 71010 CLAVICLE, COMPLETE - 73000 DUP SCAN/AORTAL/INF VENA CAV LILIAC VASCULATURE OR BYPASS GRAFTS COMPLETE - 93978 DUP SCAN/AORTAL/INF VENA CAV LILIAC VASCULATURE OR BYPASS GRAFTS LIMITED - 93979 DUP SCAN/ARTERIAL INFLOW & OUTFLOW OF ABDOMINAL, PELVIS & RETROPERITONEAL (RENAL) ORGANS, COMPLETE - 93975 DUP SCAN/EXTRACRANIAL ARTERY COMPLETE BILATERAL STUDY - 93880 DUP SCAN/EXTRACRANIAL ARTERY FOLLOW UP OR LIMITED STUDY - 93882 ECHO EXTREMITY, NON-VASCULAR - 76881 ECHO, ABDOMINAL COMPLETE - 76700 ECHO, ABDOMINAL LIMITED - 76705 ECHO, BRACHIAL ARTERY BILATERAL - 93923 ECHO, BRACHIAL ARTERY UNILATERAL - 93922 ECHO, BREAST COMPLETE - 76641 ECHO, BREAST COMPLETE - 76642 ECHOCARDIOGRAM - 93306 ECHO, PALVIA (NON OB) - 76856 ECHO, RETROPERITONEAL (RENAL) COMPLETE - 76770 ECHO, RETROPERITONEAL (RENAL) LIMITED - 76775 ECHO, SCROTUM & CONCEPTS - 76870 ECHO, SOFT TISSUE, HEAD/NECK THYROID - 76536 EKG/ECG - 93000 ELBOW, 4AP & LAT (L) - 73070 ELBOW, 4AP & LAT (R) - 73070 ELBOW, COMPLETE (L) - 73080 ELBOW, COMPLETE (R) - 73080 ENTIRE SCOLIOSIS STUDY - 72010 EYES, FOREIGN BODY - 70030 FACIAL BONES, COMPLETE - 70150 FACIAL BONES, LIMITED - 70140 FEMUR (L) - 73550 FEMUR (R) - 73550 FINGER/FINGERS (L) - 73140 FINGER/FINGERS (R) - 73140 FOOT, AP & LAT (L) - 73620 FOOT, AP & LAT (R) - 73620 FOOT, COMPLETE (L) - 73630 FOOT, COMPLETE (R) - 73630 FOREARM, AP & LAT (L) - 73090 FOREARM, AP & LAT (R) - 73090 HAND, AP & LAT (L) - 73120 HAND, AP & LAT (R) - 73120 HAND, COMPLETE (L) - 73130 HAND, COMPLETE (R) - 73130 HEEL CALCANEUS (L) - 73650 HEEL CALCANEUS (R) - 73650 HIP, UNILATERAL COMPLETE (L) - 73510 HIP, UNILATERAL COMPLETE (R) - 73510 HIPS, BILATERAL - 73520 HIPS, INFANT/CHILD - 73540 HUMERUS (L) - 73060 HUMERUS (R) - 73060 KNEE, 3 VIEW (L) - 73562 KNEE, 3 VIEW (R) - 73562 KNEE, AP & LAT (L) - 73560 KNEE, AP & LAT (R) - 73560 KNEE, COMPLETE (L) - 73564 KNEE, COMPLETE (R) - 73564 KNEES, BILATERAL STANDING (L) - 73565 KNEES, BILATERAL STANDING (R) - 73565 LLE, ARTERIAL - 93926 LLE, VENOUS - 93971 LUE, ARTERIAL - 93926 LUE, VENOUS - 93971 LUMBAR BEND 6 MIN VIEW - 72114 MANDIBLE, COMPLETE - 70110 MANDIBLE, LIMITED - 70100 MASTIODS, COMPLETE - 70130 MASTIODS, LIMITED - 70120 NASAL BONES, COMPLETE - 70160 ORBITS, COMPETE - 70200 OSSEOUS SURVEY - 77074 PELVIS, 3 VIEW - 72190 PELVIS, AP ONLY - 72170 PELVIS, LIMITED (BLADDER) - 76857 RIBS 4 VIEW PA CHEST - 71111 RIBS, 3 VIEW PA CHEST - 71101 RIBS, BILATERAL - 71110 RIBS, UNILATERAL (L) - 71100 RIBS, UNILATERAL (R) - 71100 RLE, ARTERIAL - 93926 RLE, VENOUS - 93971 RUE, ARTERIAL - 93926 RUE, VENOUS - 93971 SACRUM & COCCYX - 72220 SCAPULA (L) - 73010 SCAPULA (R) - 73010 SELLA, TURCICA - 70240 SHOULDER, COMPLETE (L) - 73030 SHOULDER, COMPLETE (R) - 73030 SHOULDER, PARTIAL (L) - 73020 SHOULDER, PARTIAL (R) - 73020 SI JOINTS, COMPLETE - 72202 SINUSES, COMPLETE - 70220 SINUSES, LIMITED - 70210 SKULL, COMPLETE - 70260 SKULL, LIMITED - 70250 SOFT TISSUE, NECK - 70360 SPINE, BENDING VIEWS - 72120 SPINE, CERVICAL 4 OR 5 VIEW - 72050 SPINE, CERVICAL AP & LAT - 72040 SPINE, CERVICAL COMPLETE - 72052 SPINE, LUMBAR AP & LAT - 72100 SPINE, LUMBAR COMPLETE - 72110 SPINE, SCOLIOSIS SURVEY - 72090 SPINE, THORACIC AP & LAT - 72070 SPINE, THORACIC COMPLETE - 72072 STERNOCLAVICULAR JOINTS - 71130 STERNUM - 71120 THORACOLUMBAR, AP & LAT - 72080 TIBIA/FIBULA (L) - 73590 TIBIA/FIBULA (R) - 73590 TMJ, BILATERAL - 70330 TMJ, OPEN & CLOSED - 70328 TMJ, UNILATERAL - 70320 TOES (L) - 73660 TOES (R) - 73660 WRIST, AP & LAT (L) - 73100 WRIST, AP & LAT (R) - 73100 WRIST, COMPLETE (L) - 73110 WRIST, COMPLETE (R) - 73110 How Many Views ICD-10 Code PLEASE SELECT AN ICD-10 CODE +PPD - R76.11 AAA W/O RUPTURE - I71.4 ABN CHEST SOUNDS - R09.89 ACUTE PULMONARY EDEMA - J81.0 ACUTE RESPIRATORY DISTRESS SYNDROME - J80 AFIB - I48.91 ANKLE PAIN (LEFT) - M25.572 ANKLE PAIN (RIGHT) - M25.571 BREAST LUMP - N63 CAD - I25.10 CAROTID BRUIT - R09.89 CHEST PAIN - R07.9 CHF - I50.9 CONGESTION - R06.89 COPD - J44.1 COUGH - R05 COUGH W/ HEMORRAGE - R04.89 DDD C SPINE - M50.30 DDD L SPINE - M51.36 DDD T SPINE - M51.34 DIZZINESS / GIDDINESS - R42 DVT (LEFT LOWER EXTREMITY) - I82.402 DVT (LEFT UPPER EXTREMITY) - I82.622 DVT (RIGHT LOWER EXTREMITY) - I82.401 DVT (RIGHT UPPER EXTREMITY) - I82.621 DYSPNEA - R06.09 EDEMA (GENERALIZED) - R60.1 EDEMA (LOCALIZED) - R60.0 ELBOW (LEFT) - M25.522 ELBOW (RIGHT) - M25.521 EPIGASTRIC - R10.13 FECAL IMPACTION - K56.49 FEMALE GENITAL SYMPTOMS - N94.89 FEVER - R50.9 FINGER PAIN (LEFT) - M79.645 FINGER PAIN (RIGHT) - M79.644 FOOT PAIN (LEFT) - M79.672 FOOT PAIN (RIGHT) - M79.671 FOREARM (LEFT) - M79.632 FOREARM (RIGHT) - M79.631 GASTROSTOMY ATTENTION ENCOUNTER - Z43.1 GASTROSTOMY STATUS - Z93.1 GENERAL - R10.84 GOITER - E04.2 HAND (LEFT) - M79.642 HAND (RIGHT) - M79.641 HIP PAIN (LEFT) - M25.552 HIP PAIN (RIGHT) - M25.551 KIDNEY CALCUNI - N20.0 KNEE PAIN (LEFT) - M25.562 KNEE PAIN (RIGHT) - M25.561 L SPINE - M54.5 NAUSEA - R11.0 NAUSEA W/ VOMITING - R11.2 OTHER CONSTIPATION - K59.09 OTHER NONSPECIFIC FINDINGS OF THE LUNG - R91.8 PAIN ABDOMINAL (LEFT LOWER QUADRANT) - R10.32 PAIN ABDOMINAL (LEFT UPPER QUADRANT) - R10.12 PAIN ABDOMINAL (RIGHT LOWER QUADRANT) - R10.31 PAIN ABDOMINAL (RIGHT UPPER QUADRANT) - R10.11 PAIN C SPINE - M54.2 PAIN IN LIMB (LEFT LOWER EXTREMITY) - M79.605 PAIN IN LIMB (LEFT UPPER EXTREMITY) - M79.602 PAIN IN LIMB (RIGHT LOWER EXTREMITY) - M79.604 PAIN IN LIMB (RIGHT UPPER EXTREMITY) - M79.601 PICC LINE - Z45.09 PNUEMONIA (SPECIFIED ORGANISM) - J16.8 PNUEMONIA (UNSPECIFIED ORGANISM) - J18.9 PPD (OTHER SPECIFIED PERIPHERAL VASCULAR DISEASE) - I73.89 PPD (UNSPECIFIED) - I73.9 PRECORDIAL PAIN - R07.2 PULMONARY FIBROSIS - J84.10 PULMONARY NODULE - R91.1 RESPIRATORY FAILURE - J96.00 RESPIRATORY FAILURE (CHRONIC) - J96.90 SHOULDER PAIN (LEFT) - M25.512 SHOULDER PAIN (RIGHT) - M25.511 SOB - R06.02 SOFT TISSUE NECK LUMP - R22.1 STENOSIS CAROTID ARTERY - I65.29 SWELLING LIMB (BILATERAL LOWER EXTREMITY) - R22.43 SWELLING LIMB (BILATERAL UPPER EXTREMITY) - R22.33 SWELLING LIMB (LEFT LOWER EXTREMITY) - R22.42 SWELLING LIMB (LEFT UPPER EXTREMITY) - R22.32 SWELLING LIMB (RIGHT LOWER EXTREMITY) - R22.41 SWELLING LIMB (RIGHT UPPER EXTREMITY) - R22.31 SWELLING MASS LUMP (CHEST) - R22.9 SWELLING MASS LUMP (TRUNK) - R22.2 T SPINE - M54.6 TB - A15.0 THIGH PAIN (LEFT) - M79.652 THIGH PAIN (RIGHT) - M79.651 THYROID NODULE - E04.1 TOES (LEFT) - M79.675 TOES (RIGHT) - M79.674 VASCULAR ACCESS DEVICE ADJUSTMENT/MANAGEMENT ENCOUNTER - Z45.2 VOMITING - R11.10 VOMITING (PROJECTILE) - R11.12 VOMITING W/O NAUSEA - R11.11 WHEEZING - R06.2 Exam Requested #3 PLEASE SELECT AN EXAM Abdomen, single view - 74018 Abdomen, 2 view - 74019 Abdomen, 3 view - 74021 Abdomen & Chest - 74022 AC JOINTS - 73050 ANKLE, AP & LAT (L) - 73560 ANKLE, AP & LAT (R) - 73560 ANKLE, COMPLETE (L) - 73610 ANKLE, COMPLETE (R) - 73610 BLE, ARTERIAL - 93925 BLE, VENOUS - 93970 BUE, ARTERIAL - 93925 BUE, VENOUS - 93970 BONE AGE STUDIES (L) - 77072 BONE AGE STUDIES (R) - 77072 BONE SURVEY, COMPLETE - 77075 CHEST, DECUBITUS - 71035 Chest, 2 view - 71046 Chest, 3 view - 71047 Chest, 4 view - 71048 CHEST, PA & LAT - 71020 CHEST, SINGLE VIEW - 71045 CLAVICLE, COMPLETE - 73000 DUP SCAN/AORTAL/INF VENA CAV LILIAC VASCULATURE OR BYPASS GRAFTS COMPLETE - 93978 DUP SCAN/AORTAL/INF VENA CAV LILIAC VASCULATURE OR BYPASS GRAFTS LIMITED - 93979 DUP SCAN/ARTERIAL INFLOW & OUTFLOW OF ABDOMINAL, PELVIS & RETROPERITONEAL (RENAL) ORGANS, COMPLETE - 93975 DUP SCAN/EXTRACRANIAL ARTERY COMPLETE BILATERAL STUDY - 93880 DUP SCAN/EXTRACRANIAL ARTERY FOLLOW UP OR LIMITED STUDY - 93882 Echography - 76881 ECHO EXTREMITY, NON-VASCULAR - 76881 ECHO, ABDOMINAL COMPLETE - 76700 ECHO, ABDOMINAL LIMITED - 76705 ECHO, BRACHIAL ARTERY BILATERAL - 93923 ECHO, BRACHIAL ARTERY UNILATERAL - 93922 ECHO, BREAST COMPLETE - 76641 ECHO, BREAST COMPLETE - 76642 ECHOCARDIOGRAM - 93306 ECHO, PALVIA (NON OB) - 76856 ECHO, RETROPERITONEAL (RENAL) COMPLETE - 76770 ECHO, RETROPERITONEAL (RENAL) LIMITED - 76775 ECHO, SCROTUM & CONCEPTS - 76870 ECHO, SOFT TISSUE, HEAD/NECK THYROID - 76536 EKG/ECG - 93000 ELBOW, 4AP & LAT (L) - 73070 ELBOW, 4AP & LAT (R) - 73070 ELBOW, COMPLETE (L) - 73080 ELBOW, COMPLETE (R) - 73080 ENTIRE SCOLIOSIS STUDY - 72010 EYES, FOREIGN BODY - 70030 FACIAL BONES, COMPLETE - 70150 FACIAL BONES, LIMITED - 70140 FEMUR (L) - 73552 FEMUR (R) - 73552 FINGER/FINGERS (L) - 73140 FINGER/FINGERS (R) - 73140 FOOT, AP & LAT (L) - 73620 FOOT, AP & LAT (R) - 73620 FOOT, COMPLETE (L) - 73630 FOOT, COMPLETE (R) - 73630 FOREARM, AP & LAT (L) - 73090 FOREARM, AP & LAT (R) - 73090 HAND, AP & LAT (L) - 73120 HAND, AP & LAT (R) - 73120 HAND, COMPLETE (L) - 73130 HAND, COMPLETE (R) - 73130 HEEL CALCANEUS (L) - 73650 HEEL CALCANEUS (R) - 73650 HIP, UNILATERAL COMPLETE (L) - 73502 HIP, UNILATERAL COMPLETE (R) - 73502 HIPS, BILATERAL - 73522 Hips, bilateral – 73522 HIPS, INFANT/CHILD - 73540 HUMERUS (L) - 73060 HUMERUS (R) - 73060 KNEE, 3 VIEW (L) - 73562 KNEE, 3 VIEW (R) - 73562 KNEE, AP & LAT (L) - 73560 KNEE, AP & LAT (R) - 73560 KNEE, COMPLETE (L) - 73564 KNEE, COMPLETE (R) - 73564 KNEES, BILATERAL STANDING (L) - 73565 KNEES, BILATERAL STANDING (R) - 73565 LLE, ARTERIAL - 93926 LLE, VENOUS - 93971 LUE, ARTERIAL - 93926 LUE, VENOUS - 93971 LUMBAR BEND 6 MIN VIEW - 72114 MANDIBLE, COMPLETE - 70110 MANDIBLE, LIMITED - 70100 MASTIODS, COMPLETE - 70130 MASTIODS, LIMITED - 70120 NASAL BONES, COMPLETE - 70160 ORBITS, COMPETE - 70200 OSSEOUS SURVEY - 77074 PELVIS, 3 VIEW - 72190 PELVIS, AP ONLY - 72170 PELVIS, LIMITED (BLADDER) - 76857 RIBS 4 VIEW PA CHEST - 71111 RIBS, 3 VIEW PA CHEST - 71101 RIBS, BILATERAL - 71110 RIBS, UNILATERAL (L) - 71100 RIBS, UNILATERAL (R) - 71100 RLE, ARTERIAL - 93926 RLE, VENOUS - 93971 RUE, ARTERIAL - 93926 RUE, VENOUS - 93971 SACRUM & COCCYX - 72220 SCAPULA (L) - 73010 SCAPULA (R) - 73010 SELLA, TURCICA - 70240 SHOULDER, COMPLETE (L) - 73030 SHOULDER, COMPLETE (R) - 73030 SHOULDER, PARTIAL (L) - 73020 SHOULDER, PARTIAL (R) - 73020 SI JOINTS, COMPLETE - 72202 SINUSES, COMPLETE - 70220 SINUSES, LIMITED - 70210 SKULL, COMPLETE - 70260 SKULL, LIMITED - 70250 SOFT TISSUE, NECK - 70360 SPINE, BENDING VIEWS - 72120 SPINE, CERVICAL 4 OR 5 VIEW - 72050 SPINE, CERVICAL AP & LAT - 72040 SPINE, CERVICAL COMPLETE - 72052 SPINE, LUMBAR AP & LAT - 72100 SPINE, LUMBAR COMPLETE - 72110 SPINE, SCOLIOSIS SURVEY - 72090 SPINE, THORACIC AP & LAT - 72070 SPINE, THORACIC COMPLETE - 72072 STERNOCLAVICULAR JOINTS - 71130 STERNUM - 71120 THORACOLUMBAR, AP & LAT - 72080 TIBIA/FIBULA (L) - 73590 TIBIA/FIBULA (R) - 73590 TMJ, BILATERAL - 70330 TMJ, OPEN & CLOSED - 70328 TMJ, UNILATERAL - 70320 TOES (L) - 73660 TOES (R) - 73660 WRIST, AP & LAT (L) - 73100 WRIST, AP & LAT (R) - 73100 WRIST, COMPLETE (L) - 73110 WRIST, COMPLETE (R) - 73110 Visceral Vascular, Aorta, limited - 93987 Visceral Vascular, Aorta, complete - 93987 How Many Views ICD10Code PLEASE SELECT AN ICD-10 CODE +PPD - R76.11 AAA W/O RUPTURE - I71.4 ABN CHEST SOUNDS - R09.89 ACUTE PULMONARY EDEMA - J81.0 ACUTE RESPIRATORY DISTRESS SYNDROME - J80 AFIB - I48.91 ANKLE PAIN (LEFT) - M25.572 ANKLE PAIN (RIGHT) - M25.571 BREAST LUMP - N63 CAD - I25.10 CAROTID BRUIT - R09.89 CHEST PAIN - R07.9 CHF - I50.9 CONGESTION - R06.89 COPD - J44.1 COUGH - R05 COUGH W/ HEMORRAGE - R04.89 DDD C SPINE - M50.30 DDD L SPINE - M51.36 DDD T SPINE - M51.34 DIZZINESS / GIDDINESS - R42 DVT (LEFT LOWER EXTREMITY) - I82.402 DVT (LEFT UPPER EXTREMITY) - I82.622 DVT (RIGHT LOWER EXTREMITY) - I82.401 DVT (RIGHT UPPER EXTREMITY) - I82.621 DYSPNEA - R06.09 EDEMA (GENERALIZED) - R60.1 EDEMA (LOCALIZED) - R60.0 ELBOW (LEFT) - M25.522 ELBOW (RIGHT) - M25.521 EPIGASTRIC - R10.13 FECAL IMPACTION - K56.49 FEMALE GENITAL SYMPTOMS - N94.89 FEVER - R50.9 FINGER PAIN (LEFT) - M79.645 FINGER PAIN (RIGHT) - M79.644 FOOT PAIN (LEFT) - M79.672 FOOT PAIN (RIGHT) - M79.671 FOREARM (LEFT) - M79.632 FOREARM (RIGHT) - M79.631 GASTROSTOMY ATTENTION ENCOUNTER - Z43.1 GASTROSTOMY STATUS - Z93.1 GENERAL - R10.84 GOITER - E04.2 HAND (LEFT) - M79.642 HAND (RIGHT) - M79.641 HIP PAIN (LEFT) - M25.552 HIP PAIN (RIGHT) - M25.551 KIDNEY CALCUNI - N20.0 KNEE PAIN (LEFT) - M25.562 KNEE PAIN (RIGHT) - M25.561 L SPINE - M54.5 NAUSEA - R11.0 NAUSEA W/ VOMITING - R11.2 OTHER CONSTIPATION - K59.09 OTHER NONSPECIFIC FINDINGS OF THE LUNG - R91.8 PAIN ABDOMINAL (LEFT LOWER QUADRANT) - R10.32 PAIN ABDOMINAL (LEFT UPPER QUADRANT) - R10.12 PAIN ABDOMINAL (RIGHT LOWER QUADRANT) - R10.31 PAIN ABDOMINAL (RIGHT UPPER QUADRANT) - R10.11 PAIN C SPINE - M54.2 PAIN IN LIMB (LEFT LOWER EXTREMITY) - M79.605 PAIN IN LIMB (LEFT UPPER EXTREMITY) - M79.602 PAIN IN LIMB (RIGHT LOWER EXTREMITY) - M79.604 PAIN IN LIMB (RIGHT UPPER EXTREMITY) - M79.601 PICC LINE - Z45.09 PNUEMONIA (SPECIFIED ORGANISM) - J16.8 PNUEMONIA (UNSPECIFIED ORGANISM) - J18.9 PPD (OTHER SPECIFIED PERIPHERAL VASCULAR DISEASE) - I73.89 PPD (UNSPECIFIED) - I73.9 PRECORDIAL PAIN - R07.2 PULMONARY FIBROSIS - J84.10 PULMONARY NODULE - R91.1 RESPIRATORY FAILURE - J96.00 RESPIRATORY FAILURE (CHRONIC) - J96.90 SHOULDER PAIN (LEFT) - M25.512 SHOULDER PAIN (RIGHT) - M25.511 SOB - R06.02 SOFT TISSUE NECK LUMP - R22.1 STENOSIS CAROTID ARTERY - I65.29 SWELLING LIMB (BILATERAL LOWER EXTREMITY) - R22.43 SWELLING LIMB (BILATERAL UPPER EXTREMITY) - R22.33 SWELLING LIMB (LEFT LOWER EXTREMITY) - R22.42 SWELLING LIMB (LEFT UPPER EXTREMITY) - R22.32 SWELLING LIMB (RIGHT LOWER EXTREMITY) - R22.41 SWELLING LIMB (RIGHT UPPER EXTREMITY) - R22.31 SWELLING MASS LUMP (CHEST) - R22.9 SWELLING MASS LUMP (TRUNK) - R22.2 T SPINE - M54.6 TB - A15.0 THIGH PAIN (LEFT) - M79.652 THIGH PAIN (RIGHT) - M79.651 THYROID NODULE - E04.1 TOES (LEFT) - M79.675 TOES (RIGHT) - M79.674 VASCULAR ACCESS DEVICE ADJUSTMENT/MANAGEMENT ENCOUNTER - Z45.2 VOMITING - R11.10 VOMITING (PROJECTILE) - R11.12 VOMITING W/O NAUSEA - R11.11 WHEEZING - R06.2 * Completed By * Ordering Physician (electronically signed by) Fax Results TO Phone Results TO Comments (75 chars left) Attach File STAT This Exam is necessary to be performed portably because transporting patient could result in further complications. submit Please turn on javascript to submit your data. 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