{"id":33,"date":"2017-10-19T17:11:52","date_gmt":"2017-10-19T17:11:52","guid":{"rendered":"http:\/\/rapidray.wpengine.com\/?page_id=33"},"modified":"2021-01-14T10:43:34","modified_gmt":"2021-01-14T17:43:34","slug":"request-tucson","status":"publish","type":"page","link":"https:\/\/www.rapid-ray.com\/request-tucson\/","title":{"rendered":"Request Tucson"},"content":{"rendered":"<p>[et_pb_section fb_built=&#8221;1&#8243; admin_label=&#8221;section&#8221; _builder_version=&#8221;3.22&#8243;][et_pb_row admin_label=&#8221;row&#8221; _builder_version=&#8221;3.25&#8243; background_size=&#8221;initial&#8221; background_position=&#8221;top_left&#8221; background_repeat=&#8221;repeat&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;3.25&#8243; custom_padding=&#8221;|||&#8221; custom_padding__hover=&#8221;|||&#8221;][et_pb_text admin_label=&#8221;Text&#8221; _builder_version=&#8221;4.7.4&#8243; background_size=&#8221;initial&#8221; background_position=&#8221;top_left&#8221; background_repeat=&#8221;repeat&#8221; hover_enabled=&#8221;0&#8243; sticky_enabled=&#8221;0&#8243;]<\/p>\n<style>\nbutton {<\/p>\n<p>font-size: 18px;<\/p>\n<p>font-weight: bold;<\/p>\n<p>color: #444444;<\/p>\n<p>font-family: \"Helvetica Neue\",Helvetica,Arial,Sans-serif;<\/p>\n<p>}<\/p>\n<\/style>\n<h3><span style=\"color: #ff6600;\"><strong>COVID-19 NOTIFICATION:\u00a0 If this is for a COVID patient, please let us know that in the comments box of this form.<\/strong><\/span><\/h3>\n<ul>\n<li><span style=\"color: #ff0000;\">Need this order STAT?\u00a0 Please call us<strong> at 520.881.2770<\/strong> after you submit your order.<\/span><\/li>\n<li><strong>If exam is needed same day, please call in orders after normal office hours.\u00a0 Our office hours are Monday thru Friday, 8am to 4pm.<\/strong><\/li>\n<li><strong>Questions?\u00a0 Call our Tucson office at 520.881.2770.<\/strong><\/li>\n<li>Fill out the online form below and click &#8220;Submit&#8221;.\u00a0 Your information is secure and HIPAA compliant.<\/li>\n<li>To save a copy of your requested information, click the &#8220;Generate PDF&#8221; button at the bottom of the form BEFORE you click the submit button.<\/li>\n<\/ul>\n<p><a href=\"https:\/\/www.rapid-ray.com\/wp-content\/uploads\/2020\/01\/print-blank-2020-pdf.pdf\" target=\"_blank\" rel=\"noopener noreferrer\"><button type=\"button\">Print Blank Form<\/button><\/a><br \/>\n\n\t\n<div id=\"system-message-container\">\n<\/div>\n\t\n<!-- BreezingForms V1.2.8 Stable Copyright(c) 2008-2009 by Markus Bopp | FacileForms Copyright 2004-2006 by Peter Koch, Chur, Switzerland.  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type=\"text\/javascript\"><!--\nJQuery(document).ready(function() {JQuery(\"#bfTooltip1023\").qtip({ position: { adjust: { screen: true } }, content: \"<div class=\\\"bfToolTipLabel\\\"><b>Hospice Covered<\/b><div\/>Check this box if hospice is covered\",style: {tip: !JQuery.browser.ie, background: \"#ffc\", color: \"#000000\", border : { color: \"#C0C0C0\", width: 1 }, name: \"cream\" } });});\n\/\/--><\/script>\n<input class=\"ff_elem\" type=\"checkbox\" name=\"ff_nm_hospicecovered[]\" value=\"Yes\" id=\"ff_elem1023\"\/>\n<\/span>\n<\/div>\n<\/div>\n<\/div>\n<div class=\"bfNoSection\" id=\"PatientInsuranceInformation\">\n<section class=\"bfSectionDescription\">\n<div class=\"header\">\n<h3>Patient Insurance Information<\/h3>\n<\/div>\n<\/section>\n<div class=\"bfNoSection\" id=\"row7\">\n<div class=\"bfClearfix\">\n<span class=\"bfElemWrap bfLabelLeft\" id=\"bfElemWrap219\">\n<label id=\"bfLabel219\" for=\"ff_elem219\"><span class=\"bfRequired\">*<\/span> \nPrimary Insurance 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= Brachial Artery unilateral - 93922<\/option>\n<option value=\"ABI Left leg ultrasound = Brachial Artery unilateral - 93922\">ABI Left leg ultrasound = Brachial Artery unilateral - 93922<\/option>\n<option value=\"ABI Right arm ultrasound = Brachial Artery unilateral - 93922\">ABI Right arm ultrasound = Brachial Artery unilateral - 93922<\/option>\n<option value=\"ABI Right leg ultrasound = Brachial Artery unilateral - 93922\">ABI Right leg ultrasound = Brachial Artery unilateral - 93922<\/option>\n<option value=\"Ankle Left 2v AP&amp;LAT = Ankle, AP&amp;LAT Left - 73560\">Ankle Left 2v AP&amp;LAT = Ankle, AP&amp;LAT Left - 73560<\/option>\n<option value=\"Ankle Left 3v Complete = Left Ankle, Complete Left - 73510\">Ankle Left 3v Complete = Left Ankle, Complete Left - 73510<\/option>\n<option value=\"Ankle Right 2v AP&amp;LAT = Ankle, AP&amp;LAT Right - 73560\">Ankle Right 2v AP&amp;LAT = Ankle, AP&amp;LAT Right - 73560<\/option>\n<option value=\"Ankle Right 3v Complete = Right Ankle, Complete Right - 73510\">Ankle Right 3v Complete = Right Ankle, Complete Right - 73510<\/option>\n<option value=\"Bladder ultrasound = Pelvis, limited (Bladder) - 76857\">Bladder ultrasound = Pelvis, limited (Bladder) - 76857<\/option>\n<option value=\"BLE, Arterial = Bilat leg arterial ultrasound\/Doppler - 93925\">BLE, Arterial = Bilat leg arterial ultrasound\/Doppler - 93925<\/option>\n<option value=\"BLE, Venous(r\/o DVT) = Bilat leg venous ultrasound\/Doppler - 93970\">BLE, Venous(r\/o DVT) = Bilat leg venous ultrasound\/Doppler - 93970<\/option>\n<option value=\"Breast ultrasound Bilateral = Breast Limited  - 76642\">Breast ultrasound Bilateral = Breast Limited  - 76642<\/option>\n<option value=\"Breast ultrasound Left = Breast Limited - 76642\">Breast ultrasound Left = Breast Limited - 76642<\/option>\n<option value=\"Breast ultrasound Right = Breast Limited - 76642\">Breast ultrasound Right = Breast Limited - 76642<\/option>\n<option value=\"BUE, Arterial = Bilat arm arterial ultrasound\/Doppler - 93925\">BUE, Arterial = Bilat arm arterial ultrasound\/Doppler - 93925<\/option>\n<option value=\"BUE, Venous(r\/o DVT) = Bilat arm venous ultrasound\/Doppler - 93970\">BUE, Venous(r\/o DVT) = Bilat arm venous ultrasound\/Doppler - 93970<\/option>\n<option value=\"Carotid Doppler = Extracranial Artery bilat study - 93880\">Carotid Doppler = Extracranial Artery bilat study - 93880<\/option>\n<option value=\"Cervical Spine, C Spine 2v AP&amp;LAT= Spine, Cervical AP&amp;LAT - 72040\">Cervical Spine, C Spine 2v AP&amp;LAT= Spine, Cervical AP&amp;LAT - 72040<\/option>\n<option value=\"Chest xray 2v AP&amp;LAT (CXR) = Chest, 2v view - 71046\">Chest xray 2v AP&amp;LAT (CXR) = Chest, 2v view - 71046<\/option>\n<option value=\"Chest xray AP (CXR) = Chest, single view - 71045\">Chest xray AP (CXR) = Chest, single view - 71045<\/option>\n<option value=\"Clavicle Left 2v AP&amp;LAT= Left Clavicle, complete Left - 73000\">Clavicle Left 2v AP&amp;LAT= Left Clavicle, complete Left - 73000<\/option>\n<option value=\"Clavicle Right 2v AP&amp;LAT = Right Clavicle, complete Right - 73000\">Clavicle Right 2v AP&amp;LAT = Right Clavicle, complete Right - 73000<\/option>\n<option value=\"Coccyx\/Sacrum (tailbone) 3v = Sacrum &amp; Coccyx complete - 72220\">Coccyx\/Sacrum (tailbone) 3v = Sacrum &amp; Coccyx complete - 72220<\/option>\n<option value=\"Echo = Echocardiogram - 93306\">Echo = Echocardiogram - 93306<\/option>\n<option value=\"EKG = EKG\/ECG - 93000\">EKG = EKG\/ECG - 93000<\/option>\n<option value=\"Elbow Left 2v AP&amp;LAT = Elbow, AP&amp;LAT Left - 73070\">Elbow Left 2v AP&amp;LAT = Elbow, AP&amp;LAT Left - 73070<\/option>\n<option value=\"Elbow Left 3v Complete = Elbow, complete Left - 73080\">Elbow Left 3v Complete = Elbow, complete Left - 73080<\/option>\n<option value=\"Elbow Right 2v AP&amp;LAT = Elbow, AP&amp;LAT Right - 73070\">Elbow Right 2v AP&amp;LAT = Elbow, AP&amp;LAT Right - 73070<\/option>\n<option value=\"Elbow Right 3v Complete = Elbow, complete Right - 73080\">Elbow Right 3v Complete = Elbow, complete Right - 73080<\/option>\n<option value=\"Facial Bones 2v = Facial bones, limited - 70140\">Facial Bones 2v = Facial bones, limited - 70140<\/option>\n<option value=\"Femur Left 2v AP&amp;LAT = Femur AP&amp;LAT Lef t- 73552\">Femur Left 2v AP&amp;LAT = Femur AP&amp;LAT Lef t- 73552<\/option>\n<option value=\"Femur Right 2v AP&amp;LAT = Femur AP&amp;LAT Right - 73552\">Femur Right 2v AP&amp;LAT = Femur AP&amp;LAT Right - 73552<\/option>\n<option value=\"Fingers\/Digits Left (1-5) = Fingers\/Fingers Left - 73140\">Fingers\/Digits Left (1-5) = Fingers\/Fingers Left - 73140<\/option>\n<option value=\"Fingers\/Digits Right (1-5) = Fingers\/Fingers Right - 73140\">Fingers\/Digits Right (1-5) = Fingers\/Fingers Right - 73140<\/option>\n<option value=\"Foot Left 2v AP&amp;LAT= Foot, AP&amp;LAT Left - 73620\">Foot Left 2v AP&amp;LAT= Foot, AP&amp;LAT Left - 73620<\/option>\n<option value=\"Foot Left 3v Complete = Foot, Complete Left - 73630\">Foot Left 3v Complete = Foot, Complete Left - 73630<\/option>\n<option value=\"Foot Right 2v AP&amp;LAT = Foot, AP&amp;LAT Right - 73620\">Foot Right 2v AP&amp;LAT = Foot, AP&amp;LAT Right - 73620<\/option>\n<option value=\"Foot Right 3v Complete = Foot, Complete Right - 73630\">Foot Right 3v Complete = Foot, Complete Right - 73630<\/option>\n<option value=\"Forearm Left 2v AP&amp;LAT = Forearm, AP&amp;LAT Left - 73090\">Forearm Left 2v AP&amp;LAT = Forearm, AP&amp;LAT Left - 73090<\/option>\n<option value=\"Forearm Right 2v AP&amp;LAT= Forearm, AP&amp;LAT Right - 73090\">Forearm Right 2v AP&amp;LAT= Forearm, AP&amp;LAT Right - 73090<\/option>\n<option value=\"Hand Left 2v AP&amp;LAT= Hand AP&amp;LAT, Left - 73120\">Hand Left 2v AP&amp;LAT= Hand AP&amp;LAT, Left - 73120<\/option>\n<option value=\"Hand Left 3v Complete = Hand Complete, Left - 73130\">Hand Left 3v Complete = Hand Complete, Left - 73130<\/option>\n<option value=\"Hand Right 2v AP&amp;LAT = Hand AP&amp;LAT, Right - 73120\">Hand Right 2v AP&amp;LAT = Hand AP&amp;LAT, Right - 73120<\/option>\n<option value=\"Hand Right 3v Complete = Hand Complete, Right - 73130\">Hand Right 3v Complete = Hand Complete, Right - 73130<\/option>\n<option value=\"Heel Left 2v AP&amp;LAT = Heel, Calcaneus Left - 73650\">Heel Left 2v AP&amp;LAT = Heel, Calcaneus Left - 73650<\/option>\n<option value=\"Heel Right 2v AP&amp;LAT = Heel, Calcaneus Right - 73650\">Heel Right 2v AP&amp;LAT = Heel, Calcaneus Right - 73650<\/option>\n<option value=\"Hip Left 2v AP&amp;LAT = Hip, unilateral AP&amp;LAT Left - 73502\">Hip Left 2v AP&amp;LAT = Hip, unilateral AP&amp;LAT Left - 73502<\/option>\n<option value=\"Hip Right 2v AP&amp;LAT = Hip, unilateral AP&amp;LAT Right - 73502\">Hip Right 2v AP&amp;LAT = Hip, unilateral AP&amp;LAT Right - 73502<\/option>\n<option value=\"Hip, Bilateral = Bilat hip 2v AP&amp;LAT - 73522\">Hip, Bilateral = Bilat hip 2v AP&amp;LAT - 73522<\/option>\n<option value=\"Hip, Bilateral w\/ AP Pelvis = Bilat hips and 1v pelvis - 73501\">Hip, Bilateral w\/ AP Pelvis = Bilat hips and 1v pelvis - 73501<\/option>\n<option value=\"Humerus Left 2v AP&amp;LAT= Humerus, AP&amp;LAT Left - 73060\">Humerus Left 2v AP&amp;LAT= Humerus, AP&amp;LAT Left - 73060<\/option>\n<option value=\"Humerus Right 2v AP&amp;LAT= Humerus, AP&amp;LAT Right - 73060\">Humerus Right 2v AP&amp;LAT= Humerus, AP&amp;LAT Right - 73060<\/option>\n<option value=\"Knee Left 2v AP&amp;LAT = Knee, AP&amp;LAT Left - 73560\">Knee Left 2v AP&amp;LAT = Knee, AP&amp;LAT Left - 73560<\/option>\n<option value=\"Knee Left 3v Complete = Knee, Complete Left - 73564\">Knee Left 3v Complete = Knee, Complete Left - 73564<\/option>\n<option value=\"Knee Right 2v AP&amp;LAT = Knee, AP&amp;LAT Right - 73560\">Knee Right 2v AP&amp;LAT = Knee, AP&amp;LAT Right - 73560<\/option>\n<option value=\"Knee Right 3v Complete = Knee, Complete Right - 73564\">Knee Right 3v Complete = Knee, Complete Right - 73564<\/option>\n<option value=\"KUB = Abdomen, single view - 74018\">KUB = Abdomen, single view - 74018<\/option>\n<option value=\"LLE, Arterial = Left leg arterial ultrasound\/Doppler - 93926\">LLE, Arterial = Left leg arterial ultrasound\/Doppler - 93926<\/option>\n<option value=\"LLE, Venous(r\/o DVT) = Left leg venous ultrasound\/Doppler - 93971\">LLE, Venous(r\/o DVT) = Left leg venous ultrasound\/Doppler - 93971<\/option>\n<option value=\"LUE, Arterial = Left arm arterial ultrasound\/Doppler - 93926\">LUE, Arterial = Left arm arterial ultrasound\/Doppler - 93926<\/option>\n<option value=\"LUE, Venous(r\/o DVT) = Left arm venous ultrasound\/Doppler - 93971\">LUE, Venous(r\/o DVT) = Left arm venous ultrasound\/Doppler - 93971<\/option>\n<option value=\"Lumbar Spine, L Spine 2v AP&amp;LAT = Spine, Lumbar AP&amp;LAT - 72100\">Lumbar Spine, L Spine 2v AP&amp;LAT = Spine, Lumbar AP&amp;LAT - 72100<\/option>\n<option value=\"Lumbosacral L\/S Spine 2v = Spine, Lumbar AP&amp;LAT - 72100\">Lumbosacral L\/S Spine 2v = Spine, Lumbar AP&amp;LAT - 72100<\/option>\n<option value=\"Mandible Left side AP&amp;LAT = Mandible, Limited Left - 70100\">Mandible Left side AP&amp;LAT = Mandible, Limited Left - 70100<\/option>\n<option value=\"Mandible Right side AP&amp;LAT = Mandible, Limited Right - 70100\">Mandible Right side AP&amp;LAT = Mandible, Limited Right - 70100<\/option>\n<option value=\"Nose\/Nasal bones 3v Complete = Nasal Bones, Limited - 70160\">Nose\/Nasal bones 3v Complete = Nasal Bones, Limited - 70160<\/option>\n<option value=\"Orbits Left (Eye socket) 2v = Orbits, Limited - 20200\">Orbits Left (Eye socket) 2v = Orbits, Limited - 20200<\/option>\n<option value=\"Orbits Right (Eye socket) 2v = Orbits, Limited - 20200\">Orbits Right (Eye socket) 2v = Orbits, Limited - 20200<\/option>\n<option value=\"Pelvic ultrasound= Echo, Pelvic (non OB) - 76856\">Pelvic ultrasound= Echo, Pelvic (non OB) - 76856<\/option>\n<option value=\"Pelvis xray 1v AP = Pelvis, AP only - 72170\">Pelvis xray 1v AP = Pelvis, AP only - 72170<\/option>\n<option value=\"Renal Artery ultrasound = Arterial inflow &amp; outflow of abd, pelvis, renal organs, limited - 93975\">Renal Artery ultrasound = Arterial inflow &amp; outflow of abd, pelvis, renal organs, limited - 93975<\/option>\n<option value=\"Renal Complete ultrasound = Retroperitoneal (Renal) complete - 76770\">Renal Complete ultrasound = Retroperitoneal (Renal) complete - 76770<\/option>\n<option value=\"Renal Limited ultrasound = Retroperitoneal (Renal) limited - 76775\">Renal Limited ultrasound = Retroperitoneal (Renal) limited - 76775<\/option>\n<option value=\"Rib Bilat xray 4v = Chest, 4 view - 71048\">Rib Bilat xray 4v = Chest, 4 view - 71048<\/option>\n<option value=\"Rib Left xray 3v Complete = Chest, 3 view - 71047\">Rib Left xray 3v Complete = Chest, 3 view - 71047<\/option>\n<option value=\"Rib Right xray 3v Complete = Chest, 3 view - 71047\">Rib Right xray 3v Complete = Chest, 3 view - 71047<\/option>\n<option value=\"RLE, Arterial = Right leg arterial ultrasound\/Doppler - 93926\">RLE, Arterial = Right leg arterial ultrasound\/Doppler - 93926<\/option>\n<option value=\"RLE, Venous(r\/o DVT) = Right leg venous ultrasound\/Doppler - 93971\">RLE, Venous(r\/o DVT) = Right leg venous ultrasound\/Doppler - 93971<\/option>\n<option value=\"RUE, Arterial = Right arm arterial ultrasound\/Doppler - 93926\">RUE, Arterial = Right arm arterial ultrasound\/Doppler - 93926<\/option>\n<option value=\"RUE, Venous (r\/o DVT) = Right arm venous ultrasound\/Doppler - 93971\">RUE, Venous (r\/o DVT) = Right arm venous ultrasound\/Doppler - 93971<\/option>\n<option value=\"S.I. Joint (Sacroiliac Joint) 3v Limited = Sacroiliac Joints, Complete - 72202\">S.I. Joint (Sacroiliac Joint) 3v Limited = Sacroiliac Joints, Complete - 72202<\/option>\n<option value=\"Sacrum\/Coccyx (tailbone) 3v = Sacrum &amp; Coccyx complete - 72220\">Sacrum\/Coccyx (tailbone) 3v = Sacrum &amp; Coccyx complete - 72220<\/option>\n<option value=\"Scapula Left 2v AP&amp;LAT = Scapula Limited Left - 73010\">Scapula Left 2v AP&amp;LAT = Scapula Limited Left - 73010<\/option>\n<option value=\"Scapula Right 2v AP&amp;LAT = Scapula Limited Right - 73010\">Scapula Right 2v AP&amp;LAT = Scapula Limited Right - 73010<\/option>\n<option value=\"Shoulder Left 2v AP&amp;LAT = Shoulder, Limited Left - 73020\">Shoulder Left 2v AP&amp;LAT = Shoulder, Limited Left - 73020<\/option>\n<option value=\"Shoulder Left 3v Complete = Shoulder, Complete Left - 73030\">Shoulder Left 3v Complete = Shoulder, Complete Left - 73030<\/option>\n<option value=\"Shoulder Right 2v AP&amp;LAT = Shoulder, Limited Right - 73020\">Shoulder Right 2v AP&amp;LAT = Shoulder, Limited Right - 73020<\/option>\n<option value=\"Shoulder Right 3v Complete = Shoulder, Complete Right - 73030\">Shoulder Right 3v Complete = Shoulder, Complete Right - 73030<\/option>\n<option value=\"Sinuses 2v Limited = Nasal Bones, limited - 70210\">Sinuses 2v Limited = Nasal Bones, limited - 70210<\/option>\n<option value=\"Skull, Limited 2v AP&amp;LAT = Skull, Limited - 70250\">Skull, Limited 2v AP&amp;LAT = Skull, Limited - 70250<\/option>\n<option value=\"Soft Tissue Axillary Left (Mass\/Lump\/Hematoma) ultrasound = Limited Breast ultrasound - 76604\">Soft Tissue Axillary Left (Mass\/Lump\/Hematoma) ultrasound = Limited Breast ultrasound - 76604<\/option>\n<option value=\"Soft Tissue Axillary Right (Mass\/Lump\/Hematoma) ultrasound = Limited Breast ultrasound - 76604\">Soft Tissue Axillary Right (Mass\/Lump\/Hematoma) ultrasound = Limited Breast ultrasound - 76604<\/option>\n<option value=\"Soft Tissue Back ultrasound = Back ultrasound - 76604\">Soft Tissue Back ultrasound = Back ultrasound - 76604<\/option>\n<option value=\"Soft Tissue Chest ultrasound = Chest ultrasound - 76604\">Soft Tissue Chest ultrasound = Chest ultrasound - 76604<\/option>\n<option value=\"Soft Tissue Head\/Neck ultrasound (Mass\/Lump\/Hematoma) = Soft Tissue, head\/neck thyroid - 76536\">Soft Tissue Head\/Neck ultrasound (Mass\/Lump\/Hematoma) = Soft Tissue, head\/neck thyroid - 76536<\/option>\n<option value=\"Soft Tissue Left Arm ultrasound (Mass\/lumps\/hematoma) = Soft Tissue extremity, non-vascular - 76881\">Soft Tissue Left Arm ultrasound (Mass\/lumps\/hematoma) = Soft Tissue extremity, non-vascular - 76881<\/option>\n<option value=\"Soft Tissue Left Leg ultrasound (Mass\/lumps\/hematoma) = Soft Tissue extremity, non-vascular - 76881\">Soft Tissue Left Leg ultrasound (Mass\/lumps\/hematoma) = Soft Tissue extremity, non-vascular - 76881<\/option>\n<option value=\"Soft Tissue Right Arm ultrasound (Mass\/lumps\/hematoma) = Soft Tissue extremity, non-vascular - 76881\">Soft Tissue Right Arm ultrasound (Mass\/lumps\/hematoma) = Soft Tissue extremity, non-vascular - 76881<\/option>\n<option value=\"Soft Tissue Right Leg ultrasound (Mass\/lumps\/hematoma) = Soft Tissue extremity, non-vascular - 76881\">Soft Tissue Right Leg ultrasound (Mass\/lumps\/hematoma) = Soft Tissue extremity, non-vascular - 76881<\/option>\n<option value=\"Testes\/Scrotum ultrasound= Echo, Scrotum &amp; Concepts - 76870\">Testes\/Scrotum ultrasound= Echo, Scrotum &amp; Concepts - 76870<\/option>\n<option value=\"Thoracic Spine, T Spine 2v AP&amp;LAT = Spine, Thoracic AP&amp;LAT - 72070\">Thoracic Spine, T Spine 2v AP&amp;LAT = Spine, Thoracic AP&amp;LAT - 72070<\/option>\n<option value=\"Thyroid ultrasound = Echo soft tissue, head\/neck thyroid - 76536\">Thyroid ultrasound = Echo soft tissue, head\/neck thyroid - 76536<\/option>\n<option value=\"Tib\/Fib Left 2v AP&amp;LAT = Tibia\/Fibula Left AP&amp;LAT - 73590\">Tib\/Fib Left 2v AP&amp;LAT = Tibia\/Fibula Left AP&amp;LAT - 73590<\/option>\n<option value=\"Tib\/Fib Right 2v AP&amp;LAT = Tibia\/Fibula Right AP&amp;LAT - 73590\">Tib\/Fib Right 2v AP&amp;LAT = Tibia\/Fibula Right AP&amp;LAT - 73590<\/option>\n<option value=\"Toes\/digits Left (1-5) 3v Complete = toes Left - 33660\">Toes\/digits Left (1-5) 3v Complete = toes Left - 33660<\/option>\n<option value=\"Toes\/digits Right (1-5) 3v Complete = toes Right - 73660\">Toes\/digits Right (1-5) 3v Complete = toes Right - 73660<\/option>\n<option value=\"Wrist Left 2v AP&amp;LAT = Wrist, AP&amp;LAT Left - 73100\">Wrist Left 2v AP&amp;LAT = Wrist, AP&amp;LAT Left - 73100<\/option>\n<option value=\"Wrist Left 3v Complete = Wrist, complete Left - 73110\">Wrist Left 3v Complete = Wrist, complete Left - 73110<\/option>\n<option value=\"Wrist Right 2v AP&amp;LAT = Wrist, AP&amp;LAT Right - 73100\">Wrist Right 2v AP&amp;LAT = Wrist, AP&amp;LAT Right - 73100<\/option>\n<option value=\"Wrist Right 3v Complete = Wrist, complete Right - 73110\">Wrist Right 3v Complete = Wrist, complete Right - 73110<\/option>\n<\/select>\n<\/span>\n<span class=\"bfElemWrap bfLabelLeft\" id=\"bfElemWrap224\">\n<label id=\"bfLabel224\" for=\"ff_elem224\"><span class=\"bfRequired\">*<\/span> \nHow Many Views<\/label>\n<input class=\"ff_elem\" style=\"width:100%\" type=\"text\" name=\"ff_nm_howmanyviews[]\" value=\"\" id=\"ff_elem224\"\/>\n<\/span>\n<span class=\"bfElemWrap bfLabelLeft\" id=\"bfElemWrap225\">\n<label id=\"bfLabel225\" for=\"ff_elem225\"><span class=\"bfRequired\">*<\/span> \nICD-10 Code<\/label>\n<select class=\"ff_elem\" name=\"ff_nm_ICD10Code[]\" id=\"ff_elem225\">\n<option value=\"\">PLEASE SELECT AN ICD-10 CODE<\/option>\n<option value=\"R76.11\">+PPD - R76.11<\/option>\n<option value=\"I71.4\">AAA W\/O RUPTURE - I71.4<\/option>\n<option value=\"R09.89\">ABN CHEST SOUNDS - R09.89<\/option>\n<option value=\"J81.0\">ACUTE PULMONARY EDEMA - J81.0<\/option>\n<option value=\"J80\">ACUTE RESPIRATORY DISTRESS SYNDROME - J80<\/option>\n<option value=\"I48.91\">AFIB - I48.91<\/option>\n<option value=\"M25.572\">ANKLE PAIN (LEFT) - M25.572<\/option>\n<option value=\"M25.571\">ANKLE PAIN (RIGHT) - M25.571<\/option>\n<option value=\"R001\">BRADYCARDIA (UNSPECIFIED) - R001<\/option>\n<option value=\"N63\">BREAST LUMP - N63<\/option>\n<option value=\"I25.10\">CAD - I25.10<\/option>\n<option value=\"R01.1\">CARDIAC MURMUR - R01.1<\/option>\n<option value=\"R09.89\">CAROTID BRUIT - R09.89<\/option>\n<option value=\"R07.9\">CHEST PAIN - R07.9<\/option>\n<option value=\"I50.9\">CHF - I50.9<\/option>\n<option value=\"R06.89\">CONGESTION - R06.89<\/option>\n<option value=\"K59.00\">CONSTIPATION (UNSPECIFIED) - K59.00<\/option>\n<option value=\"J44.1\">COPD - J44.1<\/option>\n<option value=\"R05\">COUGH - R05<\/option>\n<option value=\"R04.89\">COUGH W\/ HEMORRAGE - R04.89<\/option>\n<option value=\"M50.30\">DDD C SPINE - M50.30<\/option>\n<option value=\"M51.36\">DDD L SPINE - M51.36<\/option>\n<option value=\"M51.34\">DDD T SPINE - M51.34<\/option>\n<option value=\"R42\">DIZZINESS \/ GIDDINESS - R42<\/option>\n<option value=\"I82.402\">DVT (LEFT LOWER EXTREMITY) - I82.402<\/option>\n<option value=\"I82.622\">DVT (LEFT UPPER EXTREMITY) - I82.622<\/option>\n<option value=\"I82.401\">DVT (RIGHT LOWER EXTREMITY) - I82.401<\/option>\n<option value=\"I82.621\">DVT (RIGHT UPPER EXTREMITY) - I82.621<\/option>\n<option value=\"R06.09\">DYSPNEA - R06.09<\/option>\n<option value=\"R60.1\">EDEMA (GENERALIZED) - R60.1<\/option>\n<option value=\"R60.0\">EDEMA (LOCALIZED) - R60.0<\/option>\n<option value=\"M25.522\">ELBOW (LEFT) - M25.522<\/option>\n<option value=\"M25.521\">ELBOW (RIGHT) - M25.521<\/option>\n<option value=\"Z03.89\">ENCOUNTER FOR OBSERVATION FOR OTHER SUSPECTED DISEASES AND CONDITIONS RULED OUT - Z03.89<\/option>\n<option value=\"I10\">ESSENTIAL HYPERTENSION (PRIMARY) - I10<\/option>\n<option value=\"K56.49\">FECAL IMPACTION - K56.49<\/option>\n<option value=\"N94.89\">FEMALE GENITAL SYMPTOMS - N94.89<\/option>\n<option value=\"R50.9\">FEVER - R50.9<\/option>\n<option value=\"M79.645\">FINGER PAIN (LEFT) - M79.645<\/option>\n<option value=\"M79.644\">FINGER PAIN (RIGHT) - M79.644<\/option>\n<option value=\"M79.672\">FOOT PAIN (LEFT) - M79.672<\/option>\n<option value=\"M79.671\">FOOT PAIN (RIGHT) - M79.671<\/option>\n<option value=\"M79.632\">FOREARM (LEFT) - M79.632<\/option>\n<option value=\"M79.631\">FOREARM (RIGHT) - M79.631<\/option>\n<option value=\"Z43.1\">GASTROSTOMY ATTENTION ENCOUNTER - Z43.1<\/option>\n<option value=\"Z93.1\">GASTROSTOMY STATUS - Z93.1<\/option>\n<option value=\"E04.2\">GOITER - E04.2<\/option>\n<option value=\"M79.642\">HAND (LEFT) - M79.642<\/option>\n<option value=\"M79.641\">HAND (RIGHT) - M79.641<\/option>\n<option value=\"M25.552\">HIP PAIN (LEFT) - M25.552<\/option>\n<option value=\"M25.551\">HIP PAIN (RIGHT) - M25.551<\/option>\n<option value=\"N20.0\">KIDNEY CALCUNI - N20.0<\/option>\n<option value=\"M25.562\">KNEE PAIN (LEFT) - M25.562<\/option>\n<option value=\"M25.561\">KNEE PAIN (RIGHT) - M25.561<\/option>\n<option value=\"M54.5\">L SPINE - M54.5<\/option>\n<option value=\"R11.0\">NAUSEA - R11.0<\/option>\n<option value=\"R11.2\">NAUSEA W\/ VOMITING - R11.2<\/option>\n<option value=\"R00.8\">OTHER ABNORMALITIES OF HEART RATE - R00.8<\/option>\n<option value=\"K59.09\">OTHER CONSTIPATION - K59.09<\/option>\n<option value=\"R91.8\">OTHER NONSPECIFIC FINDINGS OF THE LUNG - R91.8<\/option>\n<option value=\"R10.13\">PAIN ABDOMINAL (EPIGASTRIC) - R10.13<\/option>\n<option value=\"R10.84\">PAIN ABDOMINAL (GENERAL) - R10.84<\/option>\n<option value=\"R10.32\">PAIN ABDOMINAL (LEFT LOWER QUADRANT) - R10.32<\/option>\n<option value=\"R10.12\">PAIN ABDOMINAL (LEFT UPPER QUADRANT) - R10.12<\/option>\n<option value=\"R10.31\">PAIN ABDOMINAL (RIGHT LOWER QUADRANT) - R10.31<\/option>\n<option value=\"R10.11\">PAIN ABDOMINAL (RIGHT UPPER QUADRANT) - R10.11<\/option>\n<option value=\"M54.2\">PAIN C SPINE - M54.2<\/option>\n<option value=\"M79.605\">PAIN IN LIMB (LEFT LOWER EXTREMITY) - M79.605<\/option>\n<option value=\"M79.602\">PAIN IN LIMB (LEFT UPPER EXTREMITY) - M79.602<\/option>\n<option value=\"M79.604\">PAIN IN LIMB (RIGHT LOWER EXTREMITY) - M79.604<\/option>\n<option value=\"M79.601\">PAIN IN LIMB (RIGHT UPPER EXTREMITY) - M79.601<\/option>\n<option value=\"Z45.09\">PICC LINE - Z45.09<\/option>\n<option value=\"J16.8\">PNUEMONIA (SPECIFIED ORGANISM) - J16.8<\/option>\n<option value=\"J18.9\">PNUEMONIA (UNSPECIFIED ORGANISM) - J18.9<\/option>\n<option value=\"I73.89\">PPD (OTHER SPECIFIED PERIPHERAL VASCULAR DISEASE) - I73.89<\/option>\n<option value=\"I73.9\">PPD (UNSPECIFIED) - I73.9<\/option>\n<option value=\"R07.2\">PRECORDIAL PAIN - R07.2<\/option>\n<option value=\"J84.10\">PULMONARY FIBROSIS - J84.10<\/option>\n<option value=\"R91.1\">PULMONARY NODULE - R91.1<\/option>\n<option value=\"J96.00\">RESPIRATORY FAILURE - J96.00<\/option>\n<option value=\"J96.90\">RESPIRATORY FAILURE (CHRONIC) - J96.90<\/option>\n<option value=\"M25.512\">SHOULDER PAIN (LEFT) - M25.512<\/option>\n<option value=\"M25.511\">SHOULDER PAIN (RIGHT) - M25.511<\/option>\n<option value=\"R06.02\">SOB - R06.02<\/option>\n<option value=\"R22.1\">SOFT TISSUE NECK LUMP - R22.1<\/option>\n<option value=\"I65.29\">STENOSIS CAROTID ARTERY - I65.29<\/option>\n<option value=\"R22.43\">SWELLING LIMB (BILATERAL LOWER EXTREMITY) - R22.43<\/option>\n<option value=\"R22.33\">SWELLING LIMB (BILATERAL UPPER EXTREMITY) - R22.33<\/option>\n<option value=\"R22.42\">SWELLING LIMB (LEFT LOWER EXTREMITY) - R22.42<\/option>\n<option value=\"R22.32\">SWELLING LIMB (LEFT UPPER EXTREMITY) - R22.32<\/option>\n<option value=\"R22.41\">SWELLING LIMB (RIGHT LOWER EXTREMITY) - R22.41<\/option>\n<option value=\"R22.31\">SWELLING LIMB (RIGHT UPPER EXTREMITY) - R22.31<\/option>\n<option value=\"R22.9\">SWELLING MASS LUMP (CHEST) - R22.9<\/option>\n<option value=\"R22.2\">SWELLING MASS LUMP (TRUNK) - R22.2<\/option>\n<option value=\"M54.6\">T SPINE - M54.6<\/option>\n<option value=\"R00.0\">TACHYCARDIA - R00.0<\/option>\n<option value=\"A15.0\">TB - A15.0<\/option>\n<option value=\"M79.652\">THIGH PAIN (LEFT) - M79.652<\/option>\n<option value=\"M79.651\">THIGH PAIN (RIGHT) - M79.651<\/option>\n<option value=\"E04.1\">THYROID NODULE - E04.1<\/option>\n<option value=\"M79.675\">TOES (LEFT) - M79.675<\/option>\n<option value=\"M79.674\">TOES (RIGHT) - M79.674<\/option>\n<option value=\"Z45.2\">VASCULAR ACCESS DEVICE ADJUSTMENT\/MANAGEMENT ENCOUNTER - Z45.2<\/option>\n<option value=\"R11.10\">VOMITING - R11.10<\/option>\n<option value=\"R11.12\">VOMITING (PROJECTILE) - R11.12<\/option>\n<option value=\"R11.11\">VOMITING W\/O NAUSEA - R11.11<\/option>\n<option value=\"R06.2\">WHEEZING - R06.2<\/option>\n<\/select>\n<\/span>\n<\/div>\n<\/div>\n<div class=\"bfNoSection\" id=\"examrequests\">\n<div class=\"bfClearfix\">\n<span class=\"bfElemWrap bfLabelLeft\" id=\"bfElemWrap226\">\n<label id=\"bfLabel226\" for=\"ff_elem226\">Portable Exam Requested #2<\/label>\n<select class=\"ff_elem\" style=\"width:100%;\" name=\"ff_nm_ExamRequested2[]\" id=\"ff_elem226\">\n<option value=\"\">PLEASE SELECT AN EXAM<\/option>\n<option value=\"AAA ultrasound Abdominal Aorta Aneurysm = Visceral Vascular, Aorta, Complete - 93978\">AAA ultrasound Abdominal Aorta Aneurysm = Visceral Vascular, Aorta, Complete - 93978<\/option>\n<option value=\"AAA ultrasound Abdominal Aorta Aneurysm= Visceral Vascular, Aorta, Limited - 93979\">AAA ultrasound Abdominal Aorta Aneurysm= Visceral Vascular, Aorta, Limited - 93979<\/option>\n<option value=\"Abdomen Limited ultrasound = Abdomen limited - 76705\">Abdomen Limited ultrasound = Abdomen limited - 76705<\/option>\n<option value=\"Abdomen ultrasound (abd us) = Abdomen complete -76700\">Abdomen ultrasound (abd us) = Abdomen complete -76700<\/option>\n<option value=\"Abdomen xray Single view = Abdomen, single view - 74018\">Abdomen xray Single view = Abdomen, single view - 74018<\/option>\n<option value=\"ABI Bilat arms ultrasound = Echo, Brachial Artery bilateral - 93923\">ABI Bilat arms ultrasound = Echo, Brachial Artery bilateral - 93923<\/option>\n<option value=\"ABI Bilat legs ultrasound = Echo, Brachial Artery bilateral - 93923\">ABI Bilat legs ultrasound = Echo, Brachial Artery bilateral - 93923<\/option>\n<option value=\"ABI Left arm ultrasound = Brachial Artery unilateral - 93922\">ABI Left arm ultrasound = Brachial Artery unilateral - 93922<\/option>\n<option value=\"ABI Left leg ultrasound = Brachial Artery unilateral - 93922\">ABI Left leg ultrasound = Brachial Artery unilateral - 93922<\/option>\n<option value=\"ABI Right arm ultrasound = Brachial Artery unilateral - 93922\">ABI Right arm ultrasound = Brachial Artery unilateral - 93922<\/option>\n<option value=\"ABI Right leg ultrasound = Brachial Artery unilateral - 93922\">ABI Right leg ultrasound = Brachial Artery unilateral - 93922<\/option>\n<option value=\"Ankle Left 2v AP&amp;LAT = Ankle, AP&amp;LAT Left - 73560\">Ankle Left 2v AP&amp;LAT = Ankle, AP&amp;LAT Left - 73560<\/option>\n<option value=\"Ankle Left 3v Complete = Left Ankle, Complete Left - 73510\">Ankle Left 3v Complete = Left Ankle, Complete Left - 73510<\/option>\n<option value=\"Ankle Right 2v AP&amp;LAT = Ankle, AP&amp;LAT Right - 73560\">Ankle Right 2v AP&amp;LAT = Ankle, AP&amp;LAT Right - 73560<\/option>\n<option value=\"Ankle Right 3v Complete = Right Ankle, Complete Right - 73510\">Ankle Right 3v Complete = Right Ankle, Complete Right - 73510<\/option>\n<option value=\"Bladder ultrasound = Pelvis, limited (Bladder) - 76857\">Bladder ultrasound = Pelvis, limited (Bladder) - 76857<\/option>\n<option value=\"BLE, Arterial = Bilat leg arterial ultrasound\/Doppler - 93925\">BLE, Arterial = Bilat leg arterial ultrasound\/Doppler - 93925<\/option>\n<option value=\"BLE, Venous(r\/o DVT) = Bilat leg venous ultrasound\/Doppler - 93970\">BLE, Venous(r\/o DVT) = Bilat leg venous ultrasound\/Doppler - 93970<\/option>\n<option value=\"Breast ultrasound Bilateral = Breast Limited  - 76642\">Breast ultrasound Bilateral = Breast Limited  - 76642<\/option>\n<option value=\"Breast ultrasound Left = Breast Limited - 76642\">Breast ultrasound Left = Breast Limited - 76642<\/option>\n<option value=\"Breast ultrasound Right = Breast Limited - 76642\">Breast ultrasound Right = Breast Limited - 76642<\/option>\n<option value=\"BUE, Arterial = Bilat arm arterial ultrasound\/Doppler - 93925\">BUE, Arterial = Bilat arm arterial ultrasound\/Doppler - 93925<\/option>\n<option value=\"BUE, Venous(r\/o DVT) = Bilat arm venous ultrasound\/Doppler - 93970\">BUE, Venous(r\/o DVT) = Bilat arm venous ultrasound\/Doppler - 93970<\/option>\n<option value=\"Carotid Doppler = Extracranial Artery bilat study - 93880\">Carotid Doppler = Extracranial Artery bilat study - 93880<\/option>\n<option value=\"Cervical Spine, C Spine 2v AP&amp;LAT= Spine, Cervical AP&amp;LAT - 72040\">Cervical Spine, C Spine 2v AP&amp;LAT= Spine, Cervical AP&amp;LAT - 72040<\/option>\n<option value=\"Chest xray 2v AP&amp;LAT (CXR) = Chest, 2v view - 71046\">Chest xray 2v AP&amp;LAT (CXR) = Chest, 2v view - 71046<\/option>\n<option value=\"Chest xray AP (CXR) = Chest, single view - 71045\">Chest xray AP (CXR) = Chest, single view - 71045<\/option>\n<option value=\"Clavicle Left 2v AP&amp;LAT= Left Clavicle, complete Left - 73000\">Clavicle Left 2v AP&amp;LAT= Left Clavicle, complete Left - 73000<\/option>\n<option value=\"Clavicle Right 2v AP&amp;LAT = Right Clavicle, complete Right - 73000\">Clavicle Right 2v AP&amp;LAT = Right Clavicle, complete Right - 73000<\/option>\n<option value=\"Coccyx\/Sacrum (tailbone) 3v = Sacrum &amp; Coccyx complete - 72220\">Coccyx\/Sacrum (tailbone) 3v = Sacrum &amp; Coccyx complete - 72220<\/option>\n<option value=\"Echo = Echocardiogram - 93306\">Echo = Echocardiogram - 93306<\/option>\n<option value=\"EKG = EKG\/ECG - 93000\">EKG = EKG\/ECG - 93000<\/option>\n<option value=\"Elbow Left 2v AP&amp;LAT = Elbow, AP&amp;LAT Left - 73070\">Elbow Left 2v AP&amp;LAT = Elbow, AP&amp;LAT Left - 73070<\/option>\n<option value=\"Elbow Left 3v Complete = Elbow, complete Left - 73080\">Elbow Left 3v Complete = Elbow, complete Left - 73080<\/option>\n<option value=\"Elbow Right 2v AP&amp;LAT = Elbow, AP&amp;LAT Right - 73070\">Elbow Right 2v AP&amp;LAT = Elbow, AP&amp;LAT Right - 73070<\/option>\n<option value=\"Elbow Right 3v Complete = Elbow, complete Right - 73080\">Elbow Right 3v Complete = Elbow, complete Right - 73080<\/option>\n<option value=\"Facial Bones 2v = Facial bones, limited - 70140\">Facial Bones 2v = Facial bones, limited - 70140<\/option>\n<option value=\"Femur Left 2v AP&amp;LAT = Femur AP&amp;LAT Lef t- 73552\">Femur Left 2v AP&amp;LAT = Femur AP&amp;LAT Lef t- 73552<\/option>\n<option value=\"Femur Right 2v AP&amp;LAT = Femur AP&amp;LAT Right - 73552\">Femur Right 2v AP&amp;LAT = Femur AP&amp;LAT Right - 73552<\/option>\n<option value=\"Fingers\/Digits Left (1-5) = Fingers\/Fingers Left - 73140\">Fingers\/Digits Left (1-5) = Fingers\/Fingers Left - 73140<\/option>\n<option value=\"Fingers\/Digits Right (1-5) = Fingers\/Fingers Right - 73140\">Fingers\/Digits Right (1-5) = Fingers\/Fingers Right - 73140<\/option>\n<option value=\"Foot Left 2v AP&amp;LAT= Foot, AP&amp;LAT Left - 73620\">Foot Left 2v AP&amp;LAT= Foot, AP&amp;LAT Left - 73620<\/option>\n<option value=\"Foot Left 3v Complete = Foot, Complete Left - 73630\">Foot Left 3v Complete = Foot, Complete Left - 73630<\/option>\n<option value=\"Foot Right 2v AP&amp;LAT = Foot, AP&amp;LAT Right - 73620\">Foot Right 2v AP&amp;LAT = Foot, AP&amp;LAT Right - 73620<\/option>\n<option value=\"Foot Right 3v Complete = Foot, Complete Right - 73630\">Foot Right 3v Complete = Foot, Complete Right - 73630<\/option>\n<option value=\"Forearm Left 2v AP&amp;LAT = Forearm, AP&amp;LAT Left - 73090\">Forearm Left 2v AP&amp;LAT = Forearm, AP&amp;LAT Left - 73090<\/option>\n<option value=\"Forearm Right 2v AP&amp;LAT= Forearm, AP&amp;LAT Right - 73090\">Forearm Right 2v AP&amp;LAT= Forearm, AP&amp;LAT Right - 73090<\/option>\n<option value=\"Hand Left 2v AP&amp;LAT= Hand AP&amp;LAT, Left - 73120\">Hand Left 2v AP&amp;LAT= Hand AP&amp;LAT, Left - 73120<\/option>\n<option value=\"Hand Left 3v Complete = Hand Complete, Left - 73130\">Hand Left 3v Complete = Hand Complete, Left - 73130<\/option>\n<option value=\"Hand Right 2v AP&amp;LAT = Hand AP&amp;LAT, Right - 73120\">Hand Right 2v AP&amp;LAT = Hand AP&amp;LAT, Right - 73120<\/option>\n<option value=\"Hand Right 3v Complete = Hand Complete, Right - 73130\">Hand Right 3v Complete = Hand Complete, Right - 73130<\/option>\n<option value=\"Heel Left 2v AP&amp;LAT = Heel, Calcaneus Left - 73650\">Heel Left 2v AP&amp;LAT = Heel, Calcaneus Left - 73650<\/option>\n<option value=\"Heel Right 2v AP&amp;LAT = Heel, Calcaneus Right - 73650\">Heel Right 2v AP&amp;LAT = Heel, Calcaneus Right - 73650<\/option>\n<option value=\"Hip Left 2v AP&amp;LAT = Hip, unilateral AP&amp;LAT Left - 73502\">Hip Left 2v AP&amp;LAT = Hip, unilateral AP&amp;LAT Left - 73502<\/option>\n<option value=\"Hip Right 2v AP&amp;LAT = Hip, unilateral AP&amp;LAT Right - 73502\">Hip Right 2v AP&amp;LAT = Hip, unilateral AP&amp;LAT Right - 73502<\/option>\n<option value=\"Hip, Bilateral = Bilat hip 2v AP&amp;LAT - 73522\">Hip, Bilateral = Bilat hip 2v AP&amp;LAT - 73522<\/option>\n<option value=\"Hip, Bilateral w\/ AP Pelvis = Bilat hips and 1v pelvis - 73501\">Hip, Bilateral w\/ AP Pelvis = Bilat hips and 1v pelvis - 73501<\/option>\n<option value=\"Humerus Left 2v AP&amp;LAT= Humerus, AP&amp;LAT Left - 73060\">Humerus Left 2v AP&amp;LAT= Humerus, AP&amp;LAT Left - 73060<\/option>\n<option value=\"Humerus Right 2v AP&amp;LAT= Humerus, AP&amp;LAT Right - 73060\">Humerus Right 2v AP&amp;LAT= Humerus, AP&amp;LAT Right - 73060<\/option>\n<option value=\"Knee Left 2v AP&amp;LAT = Knee, AP&amp;LAT Left - 73560\">Knee Left 2v AP&amp;LAT = Knee, AP&amp;LAT Left - 73560<\/option>\n<option value=\"Knee Left 3v Complete = Knee, Complete Left - 73564\">Knee Left 3v Complete = Knee, Complete Left - 73564<\/option>\n<option value=\"Knee Right 2v AP&amp;LAT = Knee, AP&amp;LAT Right - 73560\">Knee Right 2v AP&amp;LAT = Knee, AP&amp;LAT Right - 73560<\/option>\n<option value=\"Knee Right 3v Complete = Knee, Complete Right - 73564\">Knee Right 3v Complete = Knee, Complete Right - 73564<\/option>\n<option value=\"KUB = Abdomen, single view - 74018\">KUB = Abdomen, single view - 74018<\/option>\n<option value=\"LLE, Arterial = Left leg arterial ultrasound\/Doppler - 93926\">LLE, Arterial = Left leg arterial ultrasound\/Doppler - 93926<\/option>\n<option value=\"LLE, Venous(r\/o DVT) = Left leg venous ultrasound\/Doppler - 93971\">LLE, Venous(r\/o DVT) = Left leg venous ultrasound\/Doppler - 93971<\/option>\n<option value=\"LUE, Arterial = Left arm arterial ultrasound\/Doppler - 93926\">LUE, Arterial = Left arm arterial ultrasound\/Doppler - 93926<\/option>\n<option value=\"LUE, Venous(r\/o DVT) = Left arm venous ultrasound\/Doppler - 93971\">LUE, Venous(r\/o DVT) = Left arm venous ultrasound\/Doppler - 93971<\/option>\n<option value=\"Lumbar Spine, L Spine 2v AP&amp;LAT = Spine, Lumbar AP&amp;LAT - 72100\">Lumbar Spine, L Spine 2v AP&amp;LAT = Spine, Lumbar AP&amp;LAT - 72100<\/option>\n<option value=\"Lumbosacral L\/S Spine 2v = Spine, Lumbar AP&amp;LAT - 72100\">Lumbosacral L\/S Spine 2v = Spine, Lumbar AP&amp;LAT - 72100<\/option>\n<option value=\"Mandible Left side AP&amp;LAT = Mandible, Limited Left - 70100\">Mandible Left side AP&amp;LAT = Mandible, Limited Left - 70100<\/option>\n<option value=\"Mandible Right side AP&amp;LAT = Mandible, Limited Right - 70100\">Mandible Right side AP&amp;LAT = Mandible, Limited Right - 70100<\/option>\n<option value=\"Nose\/Nasal bones 3v Complete = Nasal Bones, Limited - 70160\">Nose\/Nasal bones 3v Complete = Nasal Bones, Limited - 70160<\/option>\n<option value=\"Orbits Left (Eye socket) 2v = Orbits, Limited - 20200\">Orbits Left (Eye socket) 2v = Orbits, Limited - 20200<\/option>\n<option value=\"Orbits Right (Eye socket) 2v = Orbits, Limited - 20200\">Orbits Right (Eye socket) 2v = Orbits, Limited - 20200<\/option>\n<option value=\"Pelvic ultrasound= Echo, Pelvic (non OB) - 76856\">Pelvic ultrasound= Echo, Pelvic (non OB) - 76856<\/option>\n<option value=\"Pelvis xray 1v AP = Pelvis, AP only - 72170\">Pelvis xray 1v AP = Pelvis, AP only - 72170<\/option>\n<option value=\"Renal Artery ultrasound = Arterial inflow &amp; outflow of abd, pelvis, renal organs, limited - 93975\">Renal Artery ultrasound = Arterial inflow &amp; outflow of abd, pelvis, renal organs, limited - 93975<\/option>\n<option value=\"Renal Complete ultrasound = Retroperitoneal (Renal) complete - 76770\">Renal Complete ultrasound = Retroperitoneal (Renal) complete - 76770<\/option>\n<option value=\"Renal Limited ultrasound = Retroperitoneal (Renal) limited - 76775\">Renal Limited ultrasound = Retroperitoneal (Renal) limited - 76775<\/option>\n<option value=\"Rib Bilat xray 4v = Chest, 4 view - 71048\">Rib Bilat xray 4v = Chest, 4 view - 71048<\/option>\n<option value=\"Rib Left xray 3v Complete = Chest, 3 view - 71047\">Rib Left xray 3v Complete = Chest, 3 view - 71047<\/option>\n<option value=\"Rib Right xray 3v Complete = Chest, 3 view - 71047\">Rib Right xray 3v Complete = Chest, 3 view - 71047<\/option>\n<option value=\"RLE, Arterial = Right leg arterial ultrasound\/Doppler - 93926\">RLE, Arterial = Right leg arterial ultrasound\/Doppler - 93926<\/option>\n<option value=\"RLE, Venous(r\/o DVT) = Right leg venous ultrasound\/Doppler - 93971\">RLE, Venous(r\/o DVT) = Right leg venous ultrasound\/Doppler - 93971<\/option>\n<option value=\"RUE, Arterial = Right arm arterial ultrasound\/Doppler - 93926\">RUE, Arterial = Right arm arterial ultrasound\/Doppler - 93926<\/option>\n<option value=\"RUE, Venous (r\/o DVT) = Right arm venous ultrasound\/Doppler - 93971\">RUE, Venous (r\/o DVT) = Right arm venous ultrasound\/Doppler - 93971<\/option>\n<option value=\"S.I. Joint (Sacroiliac Joint) 3v Limited = Sacroiliac Joints, Complete - 72202\">S.I. Joint (Sacroiliac Joint) 3v Limited = Sacroiliac Joints, Complete - 72202<\/option>\n<option value=\"Sacrum\/Coccyx (tailbone) 3v = Sacrum &amp; Coccyx complete - 72220\">Sacrum\/Coccyx (tailbone) 3v = Sacrum &amp; Coccyx complete - 72220<\/option>\n<option value=\"Scapula Left 2v AP&amp;LAT = Scapula Limited Left - 73010\">Scapula Left 2v AP&amp;LAT = Scapula Limited Left - 73010<\/option>\n<option value=\"Scapula Right 2v AP&amp;LAT = Scapula Limited Right - 73010\">Scapula Right 2v AP&amp;LAT = Scapula Limited Right - 73010<\/option>\n<option value=\"Shoulder Left 2v AP&amp;LAT = Shoulder, Limited Left - 73020\">Shoulder Left 2v AP&amp;LAT = Shoulder, Limited Left - 73020<\/option>\n<option value=\"Shoulder Left 3v Complete = Shoulder, Complete Left - 73030\">Shoulder Left 3v Complete = Shoulder, Complete Left - 73030<\/option>\n<option value=\"Shoulder Right 2v AP&amp;LAT = Shoulder, Limited Right - 73020\">Shoulder Right 2v AP&amp;LAT = Shoulder, Limited Right - 73020<\/option>\n<option value=\"Shoulder Right 3v Complete = Shoulder, Complete Right - 73030\">Shoulder Right 3v Complete = Shoulder, Complete Right - 73030<\/option>\n<option value=\"Sinuses 2v Limited = Nasal Bones, limited - 70210\">Sinuses 2v Limited = Nasal Bones, limited - 70210<\/option>\n<option value=\"Skull, Limited 2v AP&amp;LAT = Skull, Limited - 70250\">Skull, Limited 2v AP&amp;LAT = Skull, Limited - 70250<\/option>\n<option value=\"Soft Tissue Axillary Left (Mass\/Lump\/Hematoma) ultrasound = Limited Breast ultrasound - 76604\">Soft Tissue Axillary Left (Mass\/Lump\/Hematoma) ultrasound = Limited Breast ultrasound - 76604<\/option>\n<option value=\"Soft Tissue Axillary Right (Mass\/Lump\/Hematoma) ultrasound = Limited Breast ultrasound - 76604\">Soft Tissue Axillary Right (Mass\/Lump\/Hematoma) ultrasound = Limited Breast ultrasound - 76604<\/option>\n<option value=\"Soft Tissue Back ultrasound = Back ultrasound - 76604\">Soft Tissue Back ultrasound = Back ultrasound - 76604<\/option>\n<option value=\"Soft Tissue Chest ultrasound = Chest ultrasound - 76604\">Soft Tissue Chest ultrasound = Chest ultrasound - 76604<\/option>\n<option value=\"Soft Tissue Head\/Neck ultrasound (Mass\/Lump\/Hematoma) = Soft Tissue, head\/neck thyroid - 76536\">Soft Tissue Head\/Neck ultrasound (Mass\/Lump\/Hematoma) = Soft Tissue, head\/neck thyroid - 76536<\/option>\n<option value=\"Soft Tissue Left Arm ultrasound (Mass\/lumps\/hematoma) = Soft Tissue extremity, non-vascular - 76881\">Soft Tissue Left Arm ultrasound (Mass\/lumps\/hematoma) = Soft Tissue extremity, non-vascular - 76881<\/option>\n<option value=\"Soft Tissue Left Leg ultrasound (Mass\/lumps\/hematoma) = Soft Tissue extremity, non-vascular - 76881\">Soft Tissue Left Leg ultrasound (Mass\/lumps\/hematoma) = Soft Tissue extremity, non-vascular - 76881<\/option>\n<option value=\"Soft Tissue Right Arm ultrasound (Mass\/lumps\/hematoma) = Soft Tissue extremity, non-vascular - 76881\">Soft Tissue Right Arm ultrasound (Mass\/lumps\/hematoma) = Soft Tissue extremity, non-vascular - 76881<\/option>\n<option value=\"Soft Tissue Right Leg ultrasound (Mass\/lumps\/hematoma) = Soft Tissue extremity, non-vascular - 76881\">Soft Tissue Right Leg ultrasound (Mass\/lumps\/hematoma) = Soft Tissue extremity, non-vascular - 76881<\/option>\n<option value=\"Testes\/Scrotum ultrasound= Echo, Scrotum &amp; Concepts - 76870\">Testes\/Scrotum ultrasound= Echo, Scrotum &amp; Concepts - 76870<\/option>\n<option value=\"Thoracic Spine, T Spine 2v AP&amp;LAT = Spine, Thoracic AP&amp;LAT - 72070\">Thoracic Spine, T Spine 2v AP&amp;LAT = Spine, Thoracic AP&amp;LAT - 72070<\/option>\n<option value=\"Thyroid ultrasound = Echo soft tissue, head\/neck thyroid - 76536\">Thyroid ultrasound = Echo soft tissue, head\/neck thyroid - 76536<\/option>\n<option value=\"Tib\/Fib Left 2v AP&amp;LAT = Tibia\/Fibula Left AP&amp;LAT - 73590\">Tib\/Fib Left 2v AP&amp;LAT = Tibia\/Fibula Left AP&amp;LAT - 73590<\/option>\n<option value=\"Tib\/Fib Right 2v AP&amp;LAT = Tibia\/Fibula Right AP&amp;LAT - 73590\">Tib\/Fib Right 2v AP&amp;LAT = Tibia\/Fibula Right AP&amp;LAT - 73590<\/option>\n<option value=\"Toes\/digits Left (1-5) 3v Complete = toes Left - 33660\">Toes\/digits Left (1-5) 3v Complete = toes Left - 33660<\/option>\n<option value=\"Toes\/digits Right (1-5) 3v Complete = toes Right - 73660\">Toes\/digits Right (1-5) 3v Complete = toes Right - 73660<\/option>\n<option value=\"Wrist Left 2v AP&amp;LAT = Wrist, AP&amp;LAT Left - 73100\">Wrist Left 2v AP&amp;LAT = Wrist, AP&amp;LAT Left - 73100<\/option>\n<option value=\"Wrist Left 3v Complete = Wrist, complete Left - 73110\">Wrist Left 3v Complete = Wrist, complete Left - 73110<\/option>\n<option value=\"Wrist Right 2v AP&amp;LAT = Wrist, AP&amp;LAT Right - 73100\">Wrist Right 2v AP&amp;LAT = Wrist, AP&amp;LAT Right - 73100<\/option>\n<option value=\"Wrist Right 3v Complete = Wrist, complete Right - 73110\">Wrist Right 3v Complete = Wrist, complete Right - 73110<\/option>\n<\/select>\n<\/span>\n<span class=\"bfElemWrap bfLabelLeft\" id=\"bfElemWrap322\">\n<label id=\"bfLabel322\" for=\"ff_elem322\">How Many Views<\/label>\n<input class=\"ff_elem\" style=\"width:100%\" type=\"text\" name=\"ff_nm_howmanyviews2[]\" value=\"\" id=\"ff_elem322\"\/>\n<\/span>\n<span class=\"bfElemWrap bfLabelLeft\" id=\"bfElemWrap323\">\n<label id=\"bfLabel323\" for=\"ff_elem323\">ICD-10 Code<\/label>\n<select class=\"ff_elem\" name=\"ff_nm_ICD10Code2[]\" id=\"ff_elem323\">\n<option value=\"\">PLEASE SELECT AN ICD-10 CODE<\/option>\n<option value=\"R76.11\">+PPD - R76.11<\/option>\n<option value=\"I71.4\">AAA W\/O RUPTURE - I71.4<\/option>\n<option value=\"R09.89\">ABN CHEST SOUNDS - R09.89<\/option>\n<option value=\"J81.0\">ACUTE PULMONARY EDEMA - J81.0<\/option>\n<option value=\"J80\">ACUTE RESPIRATORY DISTRESS SYNDROME - J80<\/option>\n<option value=\"I48.91\">AFIB - I48.91<\/option>\n<option value=\"M25.572\">ANKLE PAIN (LEFT) - M25.572<\/option>\n<option value=\"M25.571\">ANKLE PAIN (RIGHT) - M25.571<\/option>\n<option value=\"R001\">BRADYCARDIA (UNSPECIFIED) - R001<\/option>\n<option value=\"N63\">BREAST LUMP - N63<\/option>\n<option value=\"I25.10\">CAD - I25.10<\/option>\n<option value=\"R01.1\">CARDIAC MURMUR - R01.1<\/option>\n<option value=\"R09.89\">CAROTID BRUIT - R09.89<\/option>\n<option value=\"R07.9\">CHEST PAIN - R07.9<\/option>\n<option value=\"I50.9\">CHF - I50.9<\/option>\n<option value=\"R06.89\">CONGESTION - R06.89<\/option>\n<option value=\"K59.00\">CONSTIPATION (UNSPECIFIED) - K59.00<\/option>\n<option value=\"J44.1\">COPD - J44.1<\/option>\n<option value=\"R05\">COUGH - R05<\/option>\n<option value=\"R04.89\">COUGH W\/ HEMORRAGE - R04.89<\/option>\n<option value=\"M50.30\">DDD C SPINE - M50.30<\/option>\n<option value=\"M51.36\">DDD L SPINE - M51.36<\/option>\n<option value=\"M51.34\">DDD T SPINE - M51.34<\/option>\n<option value=\"R42\">DIZZINESS \/ GIDDINESS - R42<\/option>\n<option value=\"I82.402\">DVT (LEFT LOWER EXTREMITY) - I82.402<\/option>\n<option value=\"I82.622\">DVT (LEFT UPPER EXTREMITY) - I82.622<\/option>\n<option value=\"I82.401\">DVT (RIGHT LOWER EXTREMITY) - I82.401<\/option>\n<option value=\"I82.621\">DVT (RIGHT UPPER EXTREMITY) - I82.621<\/option>\n<option value=\"R06.09\">DYSPNEA - R06.09<\/option>\n<option value=\"R60.1\">EDEMA (GENERALIZED) - R60.1<\/option>\n<option value=\"R60.0\">EDEMA (LOCALIZED) - R60.0<\/option>\n<option value=\"M25.522\">ELBOW (LEFT) - M25.522<\/option>\n<option value=\"M25.521\">ELBOW (RIGHT) - M25.521<\/option>\n<option value=\"Z03.89\">ENCOUNTER FOR OBSERVATION FOR OTHER SUSPECTED DISEASES AND CONDITIONS RULED OUT - Z03.89<\/option>\n<option value=\"I10\">ESSENTIAL HYPERTENSION (PRIMARY) - I10<\/option>\n<option value=\"K56.49\">FECAL IMPACTION - K56.49<\/option>\n<option value=\"N94.89\">FEMALE GENITAL SYMPTOMS - N94.89<\/option>\n<option value=\"R50.9\">FEVER - R50.9<\/option>\n<option value=\"M79.645\">FINGER PAIN (LEFT) - M79.645<\/option>\n<option value=\"M79.644\">FINGER PAIN (RIGHT) - M79.644<\/option>\n<option value=\"M79.672\">FOOT PAIN (LEFT) - M79.672<\/option>\n<option value=\"M79.671\">FOOT PAIN (RIGHT) - M79.671<\/option>\n<option value=\"M79.632\">FOREARM (LEFT) - M79.632<\/option>\n<option value=\"M79.631\">FOREARM (RIGHT) - M79.631<\/option>\n<option value=\"Z43.1\">GASTROSTOMY ATTENTION ENCOUNTER - Z43.1<\/option>\n<option value=\"Z93.1\">GASTROSTOMY STATUS - Z93.1<\/option>\n<option value=\"E04.2\">GOITER - E04.2<\/option>\n<option value=\"M79.642\">HAND (LEFT) - M79.642<\/option>\n<option value=\"M79.641\">HAND (RIGHT) - M79.641<\/option>\n<option value=\"M25.552\">HIP PAIN (LEFT) - M25.552<\/option>\n<option value=\"M25.551\">HIP PAIN (RIGHT) - M25.551<\/option>\n<option value=\"N20.0\">KIDNEY CALCUNI - N20.0<\/option>\n<option value=\"M25.562\">KNEE PAIN (LEFT) - M25.562<\/option>\n<option value=\"M25.561\">KNEE PAIN (RIGHT) - M25.561<\/option>\n<option value=\"M54.5\">L SPINE - M54.5<\/option>\n<option value=\"R11.0\">NAUSEA - R11.0<\/option>\n<option value=\"R11.2\">NAUSEA W\/ VOMITING - R11.2<\/option>\n<option value=\"R00.8\">OTHER ABNORMALITIES OF HEART RATE - R00.8<\/option>\n<option value=\"K59.09\">OTHER CONSTIPATION - K59.09<\/option>\n<option value=\"R91.8\">OTHER NONSPECIFIC FINDINGS OF THE LUNG - R91.8<\/option>\n<option value=\"R10.13\">PAIN ABDOMINAL (EPIGASTRIC) - R10.13<\/option>\n<option value=\"R10.84\">PAIN ABDOMINAL (GENERAL) - R10.84<\/option>\n<option value=\"R10.32\">PAIN ABDOMINAL (LEFT LOWER QUADRANT) - R10.32<\/option>\n<option value=\"R10.12\">PAIN ABDOMINAL (LEFT UPPER QUADRANT) - R10.12<\/option>\n<option value=\"R10.31\">PAIN ABDOMINAL (RIGHT LOWER QUADRANT) - R10.31<\/option>\n<option value=\"R10.11\">PAIN ABDOMINAL (RIGHT UPPER QUADRANT) - R10.11<\/option>\n<option value=\"M54.2\">PAIN C SPINE - M54.2<\/option>\n<option value=\"M79.605\">PAIN IN LIMB (LEFT LOWER EXTREMITY) - M79.605<\/option>\n<option value=\"M79.602\">PAIN IN LIMB (LEFT UPPER EXTREMITY) - M79.602<\/option>\n<option value=\"M79.604\">PAIN IN LIMB (RIGHT LOWER EXTREMITY) - M79.604<\/option>\n<option value=\"M79.601\">PAIN IN LIMB (RIGHT UPPER EXTREMITY) - M79.601<\/option>\n<option value=\"Z45.09\">PICC LINE - Z45.09<\/option>\n<option value=\"J16.8\">PNUEMONIA (SPECIFIED ORGANISM) - J16.8<\/option>\n<option value=\"J18.9\">PNUEMONIA (UNSPECIFIED ORGANISM) - J18.9<\/option>\n<option value=\"I73.89\">PPD (OTHER SPECIFIED PERIPHERAL VASCULAR DISEASE) - I73.89<\/option>\n<option value=\"I73.9\">PPD (UNSPECIFIED) - I73.9<\/option>\n<option value=\"R07.2\">PRECORDIAL PAIN - R07.2<\/option>\n<option value=\"J84.10\">PULMONARY FIBROSIS - J84.10<\/option>\n<option value=\"R91.1\">PULMONARY NODULE - R91.1<\/option>\n<option value=\"J96.00\">RESPIRATORY FAILURE - J96.00<\/option>\n<option value=\"J96.90\">RESPIRATORY FAILURE (CHRONIC) - J96.90<\/option>\n<option value=\"M25.512\">SHOULDER PAIN (LEFT) - M25.512<\/option>\n<option value=\"M25.511\">SHOULDER PAIN (RIGHT) - M25.511<\/option>\n<option value=\"R06.02\">SOB - R06.02<\/option>\n<option value=\"R22.1\">SOFT TISSUE NECK LUMP - R22.1<\/option>\n<option value=\"I65.29\">STENOSIS CAROTID ARTERY - I65.29<\/option>\n<option value=\"R22.43\">SWELLING LIMB (BILATERAL LOWER EXTREMITY) - R22.43<\/option>\n<option value=\"R22.33\">SWELLING LIMB (BILATERAL UPPER EXTREMITY) - R22.33<\/option>\n<option value=\"R22.42\">SWELLING LIMB (LEFT LOWER EXTREMITY) - R22.42<\/option>\n<option value=\"R22.32\">SWELLING LIMB (LEFT UPPER EXTREMITY) - R22.32<\/option>\n<option value=\"R22.41\">SWELLING LIMB (RIGHT LOWER EXTREMITY) - R22.41<\/option>\n<option value=\"R22.31\">SWELLING LIMB (RIGHT UPPER EXTREMITY) - R22.31<\/option>\n<option value=\"R22.9\">SWELLING MASS LUMP (CHEST) - R22.9<\/option>\n<option value=\"R22.2\">SWELLING MASS LUMP (TRUNK) - R22.2<\/option>\n<option value=\"M54.6\">T SPINE - M54.6<\/option>\n<option value=\"R00.0\">TACHYCARDIA - R00.0<\/option>\n<option value=\"A15.0\">TB - A15.0<\/option>\n<option value=\"M79.652\">THIGH PAIN (LEFT) - M79.652<\/option>\n<option value=\"M79.651\">THIGH PAIN (RIGHT) - M79.651<\/option>\n<option value=\"E04.1\">THYROID NODULE - E04.1<\/option>\n<option value=\"M79.675\">TOES (LEFT) - M79.675<\/option>\n<option value=\"M79.674\">TOES (RIGHT) - M79.674<\/option>\n<option value=\"Z45.2\">VASCULAR ACCESS DEVICE ADJUSTMENT\/MANAGEMENT ENCOUNTER - Z45.2<\/option>\n<option value=\"R11.10\">VOMITING - R11.10<\/option>\n<option value=\"R11.12\">VOMITING (PROJECTILE) - R11.12<\/option>\n<option value=\"R11.11\">VOMITING W\/O NAUSEA - R11.11<\/option>\n<option value=\"R06.2\">WHEEZING - R06.2<\/option>\n<\/select>\n<\/span>\n<span class=\"bfElemWrap bfLabelLeft\" id=\"bfElemWrap227\">\n<label id=\"bfLabel227\" for=\"ff_elem227\">Portable Exam Requested #3<\/label>\n<select class=\"ff_elem\" style=\"width:100%;\" name=\"ff_nm_ExamRequested3[]\" id=\"ff_elem227\">\n<option value=\"\">PLEASE SELECT AN EXAM<\/option>\n<option value=\"AAA ultrasound Abdominal Aorta Aneurysm = Visceral Vascular, Aorta, Complete - 93978\">AAA ultrasound Abdominal Aorta Aneurysm = Visceral Vascular, Aorta, Complete - 93978<\/option>\n<option value=\"AAA ultrasound Abdominal Aorta Aneurysm= Visceral Vascular, Aorta, Limited - 93979\">AAA ultrasound Abdominal Aorta Aneurysm= Visceral Vascular, Aorta, Limited - 93979<\/option>\n<option value=\"Abdomen Limited ultrasound = Abdomen limited - 76705\">Abdomen Limited ultrasound = Abdomen limited - 76705<\/option>\n<option value=\"Abdomen ultrasound (abd us) = Abdomen complete -76700\">Abdomen ultrasound (abd us) = Abdomen complete -76700<\/option>\n<option value=\"Abdomen xray Single view = Abdomen, single view - 74018\">Abdomen xray Single view = Abdomen, single view - 74018<\/option>\n<option value=\"ABI Bilat arms ultrasound = Echo, Brachial Artery bilateral - 93923\">ABI Bilat arms ultrasound = Echo, Brachial Artery bilateral - 93923<\/option>\n<option value=\"ABI Bilat legs ultrasound = Echo, Brachial Artery bilateral - 93923\">ABI Bilat legs ultrasound = Echo, Brachial Artery bilateral - 93923<\/option>\n<option value=\"ABI Left arm ultrasound = Brachial Artery unilateral - 93922\">ABI Left arm ultrasound = Brachial Artery unilateral - 93922<\/option>\n<option value=\"ABI Left leg ultrasound = Brachial Artery unilateral - 93922\">ABI Left leg ultrasound = Brachial Artery unilateral - 93922<\/option>\n<option value=\"ABI Right arm ultrasound = Brachial Artery unilateral - 93922\">ABI Right arm ultrasound = Brachial Artery unilateral - 93922<\/option>\n<option value=\"ABI Right leg ultrasound = Brachial Artery unilateral - 93922\">ABI Right leg ultrasound = Brachial Artery unilateral - 93922<\/option>\n<option value=\"Ankle Left 2v AP&amp;LAT = Ankle, AP&amp;LAT Left - 73560\">Ankle Left 2v AP&amp;LAT = Ankle, AP&amp;LAT Left - 73560<\/option>\n<option value=\"Ankle Left 3v Complete = Left Ankle, Complete Left - 73510\">Ankle Left 3v Complete = Left Ankle, Complete Left - 73510<\/option>\n<option value=\"Ankle Right 2v AP&amp;LAT = Ankle, AP&amp;LAT Right - 73560\">Ankle Right 2v AP&amp;LAT = Ankle, AP&amp;LAT Right - 73560<\/option>\n<option value=\"Ankle Right 3v Complete = Right Ankle, Complete Right - 73510\">Ankle Right 3v Complete = Right Ankle, Complete Right - 73510<\/option>\n<option value=\"Bladder ultrasound = Pelvis, limited (Bladder) - 76857\">Bladder ultrasound = Pelvis, limited (Bladder) - 76857<\/option>\n<option value=\"BLE, Arterial = Bilat leg arterial ultrasound\/Doppler - 93925\">BLE, Arterial = Bilat leg arterial ultrasound\/Doppler - 93925<\/option>\n<option value=\"BLE, Venous(r\/o DVT) = Bilat leg venous ultrasound\/Doppler - 93970\">BLE, Venous(r\/o DVT) = Bilat leg venous ultrasound\/Doppler - 93970<\/option>\n<option value=\"Breast ultrasound Bilateral = Breast Limited  - 76642\">Breast ultrasound Bilateral = Breast Limited  - 76642<\/option>\n<option value=\"Breast ultrasound Left = Breast Limited - 76642\">Breast ultrasound Left = Breast Limited - 76642<\/option>\n<option value=\"Breast ultrasound Right = Breast Limited - 76642\">Breast ultrasound Right = Breast Limited - 76642<\/option>\n<option value=\"BUE, Arterial = Bilat arm arterial ultrasound\/Doppler - 93925\">BUE, Arterial = Bilat arm arterial ultrasound\/Doppler - 93925<\/option>\n<option value=\"BUE, Venous(r\/o DVT) = Bilat arm venous ultrasound\/Doppler - 93970\">BUE, Venous(r\/o DVT) = Bilat arm venous ultrasound\/Doppler - 93970<\/option>\n<option value=\"Carotid Doppler = Extracranial Artery bilat study - 93880\">Carotid Doppler = Extracranial Artery bilat study - 93880<\/option>\n<option value=\"Cervical Spine, C Spine 2v AP&amp;LAT= Spine, Cervical AP&amp;LAT - 72040\">Cervical Spine, C Spine 2v AP&amp;LAT= Spine, Cervical AP&amp;LAT - 72040<\/option>\n<option value=\"Chest xray 2v AP&amp;LAT (CXR) = Chest, 2v view - 71046\">Chest xray 2v AP&amp;LAT (CXR) = Chest, 2v view - 71046<\/option>\n<option value=\"Chest xray AP (CXR) = Chest, single view - 71045\">Chest xray AP (CXR) = Chest, single view - 71045<\/option>\n<option value=\"Clavicle Left 2v AP&amp;LAT= Left Clavicle, complete Left - 73000\">Clavicle Left 2v AP&amp;LAT= Left Clavicle, complete Left - 73000<\/option>\n<option value=\"Clavicle Right 2v AP&amp;LAT = Right Clavicle, complete Right - 73000\">Clavicle Right 2v AP&amp;LAT = Right Clavicle, complete Right - 73000<\/option>\n<option value=\"Coccyx\/Sacrum (tailbone) 3v = Sacrum &amp; Coccyx complete - 72220\">Coccyx\/Sacrum (tailbone) 3v = Sacrum &amp; Coccyx complete - 72220<\/option>\n<option value=\"Echo = Echocardiogram - 93306\">Echo = Echocardiogram - 93306<\/option>\n<option value=\"EKG = EKG\/ECG - 93000\">EKG = EKG\/ECG - 93000<\/option>\n<option value=\"Elbow Left 2v AP&amp;LAT = Elbow, AP&amp;LAT Left - 73070\">Elbow Left 2v AP&amp;LAT = Elbow, AP&amp;LAT Left - 73070<\/option>\n<option value=\"Elbow Left 3v Complete = Elbow, complete Left - 73080\">Elbow Left 3v Complete = Elbow, complete Left - 73080<\/option>\n<option value=\"Elbow Right 2v AP&amp;LAT = Elbow, AP&amp;LAT Right - 73070\">Elbow Right 2v AP&amp;LAT = Elbow, AP&amp;LAT Right - 73070<\/option>\n<option value=\"Elbow Right 3v Complete = Elbow, complete Right - 73080\">Elbow Right 3v Complete = Elbow, complete Right - 73080<\/option>\n<option value=\"Facial Bones 2v = Facial bones, limited - 70140\">Facial Bones 2v = Facial bones, limited - 70140<\/option>\n<option value=\"Femur Left 2v AP&amp;LAT = Femur AP&amp;LAT Lef t- 73552\">Femur Left 2v AP&amp;LAT = Femur AP&amp;LAT Lef t- 73552<\/option>\n<option value=\"Femur Right 2v AP&amp;LAT = Femur AP&amp;LAT Right - 73552\">Femur Right 2v AP&amp;LAT = Femur AP&amp;LAT Right - 73552<\/option>\n<option value=\"Fingers\/Digits Left (1-5) = Fingers\/Fingers Left - 73140\">Fingers\/Digits Left (1-5) = Fingers\/Fingers Left - 73140<\/option>\n<option value=\"Fingers\/Digits Right (1-5) = Fingers\/Fingers Right - 73140\">Fingers\/Digits Right (1-5) = Fingers\/Fingers Right - 73140<\/option>\n<option value=\"Foot Left 2v AP&amp;LAT= Foot, AP&amp;LAT Left - 73620\">Foot Left 2v AP&amp;LAT= Foot, AP&amp;LAT Left - 73620<\/option>\n<option value=\"Foot Left 3v Complete = Foot, Complete Left - 73630\">Foot Left 3v Complete = Foot, Complete Left - 73630<\/option>\n<option value=\"Foot Right 2v AP&amp;LAT = Foot, AP&amp;LAT Right - 73620\">Foot Right 2v AP&amp;LAT = Foot, AP&amp;LAT Right - 73620<\/option>\n<option value=\"Foot Right 3v Complete = Foot, Complete Right - 73630\">Foot Right 3v Complete = Foot, Complete Right - 73630<\/option>\n<option value=\"Forearm Left 2v AP&amp;LAT = Forearm, AP&amp;LAT Left - 73090\">Forearm Left 2v AP&amp;LAT = Forearm, AP&amp;LAT Left - 73090<\/option>\n<option value=\"Forearm Right 2v AP&amp;LAT= Forearm, AP&amp;LAT Right - 73090\">Forearm Right 2v AP&amp;LAT= Forearm, AP&amp;LAT Right - 73090<\/option>\n<option value=\"Hand Left 2v AP&amp;LAT= Hand AP&amp;LAT, Left - 73120\">Hand Left 2v AP&amp;LAT= Hand AP&amp;LAT, Left - 73120<\/option>\n<option value=\"Hand Left 3v Complete = Hand Complete, Left - 73130\">Hand Left 3v Complete = Hand Complete, Left - 73130<\/option>\n<option value=\"Hand Right 2v AP&amp;LAT = Hand AP&amp;LAT, Right - 73120\">Hand Right 2v AP&amp;LAT = Hand AP&amp;LAT, Right - 73120<\/option>\n<option value=\"Hand Right 3v Complete = Hand Complete, Right - 73130\">Hand Right 3v Complete = Hand Complete, Right - 73130<\/option>\n<option value=\"Heel Left 2v AP&amp;LAT = Heel, Calcaneus Left - 73650\">Heel Left 2v AP&amp;LAT = Heel, Calcaneus Left - 73650<\/option>\n<option value=\"Heel Right 2v AP&amp;LAT = Heel, Calcaneus Right - 73650\">Heel Right 2v AP&amp;LAT = Heel, Calcaneus Right - 73650<\/option>\n<option value=\"Hip Left 2v AP&amp;LAT = Hip, unilateral AP&amp;LAT Left - 73502\">Hip Left 2v AP&amp;LAT = Hip, unilateral AP&amp;LAT Left - 73502<\/option>\n<option value=\"Hip Right 2v AP&amp;LAT = Hip, unilateral AP&amp;LAT Right - 73502\">Hip Right 2v AP&amp;LAT = Hip, unilateral AP&amp;LAT Right - 73502<\/option>\n<option value=\"Hip, Bilateral = Bilat hip 2v AP&amp;LAT - 73522\">Hip, Bilateral = Bilat hip 2v AP&amp;LAT - 73522<\/option>\n<option value=\"Hip, Bilateral w\/ AP Pelvis = Bilat hips and 1v pelvis - 73501\">Hip, Bilateral w\/ AP Pelvis = Bilat hips and 1v pelvis - 73501<\/option>\n<option value=\"Humerus Left 2v AP&amp;LAT= Humerus, AP&amp;LAT Left - 73060\">Humerus Left 2v AP&amp;LAT= Humerus, AP&amp;LAT Left - 73060<\/option>\n<option value=\"Humerus Right 2v AP&amp;LAT= Humerus, AP&amp;LAT Right - 73060\">Humerus Right 2v AP&amp;LAT= Humerus, AP&amp;LAT Right - 73060<\/option>\n<option value=\"Knee Left 2v AP&amp;LAT = Knee, AP&amp;LAT Left - 73560\">Knee Left 2v AP&amp;LAT = Knee, AP&amp;LAT Left - 73560<\/option>\n<option value=\"Knee Left 3v Complete = Knee, Complete Left - 73564\">Knee Left 3v Complete = Knee, Complete Left - 73564<\/option>\n<option value=\"Knee Right 2v AP&amp;LAT = Knee, AP&amp;LAT Right - 73560\">Knee Right 2v AP&amp;LAT = Knee, AP&amp;LAT Right - 73560<\/option>\n<option value=\"Knee Right 3v Complete = Knee, Complete Right - 73564\">Knee Right 3v Complete = Knee, Complete Right - 73564<\/option>\n<option value=\"KUB = Abdomen, single view - 74018\">KUB = Abdomen, single view - 74018<\/option>\n<option value=\"LLE, Arterial = Left leg arterial ultrasound\/Doppler - 93926\">LLE, Arterial = Left leg arterial ultrasound\/Doppler - 93926<\/option>\n<option value=\"LLE, Venous(r\/o DVT) = Left leg venous ultrasound\/Doppler - 93971\">LLE, Venous(r\/o DVT) = Left leg venous ultrasound\/Doppler - 93971<\/option>\n<option value=\"LUE, Arterial = Left arm arterial ultrasound\/Doppler - 93926\">LUE, Arterial = Left arm arterial ultrasound\/Doppler - 93926<\/option>\n<option value=\"LUE, Venous(r\/o DVT) = Left arm venous ultrasound\/Doppler - 93971\">LUE, Venous(r\/o DVT) = Left arm venous ultrasound\/Doppler - 93971<\/option>\n<option value=\"Lumbar Spine, L Spine 2v AP&amp;LAT = Spine, Lumbar AP&amp;LAT - 72100\">Lumbar Spine, L Spine 2v AP&amp;LAT = Spine, Lumbar AP&amp;LAT - 72100<\/option>\n<option value=\"Lumbosacral L\/S Spine 2v = Spine, Lumbar AP&amp;LAT - 72100\">Lumbosacral L\/S Spine 2v = Spine, Lumbar AP&amp;LAT - 72100<\/option>\n<option value=\"Mandible Left side AP&amp;LAT = Mandible, Limited Left - 70100\">Mandible Left side AP&amp;LAT = Mandible, Limited Left - 70100<\/option>\n<option value=\"Mandible Right side AP&amp;LAT = Mandible, Limited Right - 70100\">Mandible Right side AP&amp;LAT = Mandible, Limited Right - 70100<\/option>\n<option value=\"Nose\/Nasal bones 3v Complete = Nasal Bones, Limited - 70160\">Nose\/Nasal bones 3v Complete = Nasal Bones, Limited - 70160<\/option>\n<option value=\"Orbits Left (Eye socket) 2v = Orbits, Limited - 20200\">Orbits Left (Eye socket) 2v = Orbits, Limited - 20200<\/option>\n<option value=\"Orbits Right (Eye socket) 2v = Orbits, Limited - 20200\">Orbits Right (Eye socket) 2v = Orbits, Limited - 20200<\/option>\n<option value=\"Pelvic ultrasound= Echo, Pelvic (non OB) - 76856\">Pelvic ultrasound= Echo, Pelvic (non OB) - 76856<\/option>\n<option value=\"Pelvis xray 1v AP = Pelvis, AP only - 72170\">Pelvis xray 1v AP = Pelvis, AP only - 72170<\/option>\n<option value=\"Renal Artery ultrasound = Arterial inflow &amp; outflow of abd, pelvis, renal organs, limited - 93975\">Renal Artery ultrasound = Arterial inflow &amp; outflow of abd, pelvis, renal organs, limited - 93975<\/option>\n<option value=\"Renal Complete ultrasound = Retroperitoneal (Renal) complete - 76770\">Renal Complete ultrasound = Retroperitoneal (Renal) complete - 76770<\/option>\n<option value=\"Renal Limited ultrasound = Retroperitoneal (Renal) limited - 76775\">Renal Limited ultrasound = Retroperitoneal (Renal) limited - 76775<\/option>\n<option value=\"Rib Bilat xray 4v = Chest, 4 view - 71048\">Rib Bilat xray 4v = Chest, 4 view - 71048<\/option>\n<option value=\"Rib Left xray 3v Complete = Chest, 3 view - 71047\">Rib Left xray 3v Complete = Chest, 3 view - 71047<\/option>\n<option value=\"Rib Right xray 3v Complete = Chest, 3 view - 71047\">Rib Right xray 3v Complete = Chest, 3 view - 71047<\/option>\n<option value=\"RLE, Arterial = Right leg arterial ultrasound\/Doppler - 93926\">RLE, Arterial = Right leg arterial ultrasound\/Doppler - 93926<\/option>\n<option value=\"RLE, Venous(r\/o DVT) = Right leg venous ultrasound\/Doppler - 93971\">RLE, Venous(r\/o DVT) = Right leg venous ultrasound\/Doppler - 93971<\/option>\n<option value=\"RUE, Arterial = Right arm arterial ultrasound\/Doppler - 93926\">RUE, Arterial = Right arm arterial ultrasound\/Doppler - 93926<\/option>\n<option value=\"RUE, Venous (r\/o DVT) = Right arm venous ultrasound\/Doppler - 93971\">RUE, Venous (r\/o DVT) = Right arm venous ultrasound\/Doppler - 93971<\/option>\n<option value=\"S.I. Joint (Sacroiliac Joint) 3v Limited = Sacroiliac Joints, Complete - 72202\">S.I. Joint (Sacroiliac Joint) 3v Limited = Sacroiliac Joints, Complete - 72202<\/option>\n<option value=\"Sacrum\/Coccyx (tailbone) 3v = Sacrum &amp; Coccyx complete - 72220\">Sacrum\/Coccyx (tailbone) 3v = Sacrum &amp; Coccyx complete - 72220<\/option>\n<option value=\"Scapula Left 2v AP&amp;LAT = Scapula Limited Left - 73010\">Scapula Left 2v AP&amp;LAT = Scapula Limited Left - 73010<\/option>\n<option value=\"Scapula Right 2v AP&amp;LAT = Scapula Limited Right - 73010\">Scapula Right 2v AP&amp;LAT = Scapula Limited Right - 73010<\/option>\n<option value=\"Shoulder Left 2v AP&amp;LAT = Shoulder, Limited Left - 73020\">Shoulder Left 2v AP&amp;LAT = Shoulder, Limited Left - 73020<\/option>\n<option value=\"Shoulder Left 3v Complete = Shoulder, Complete Left - 73030\">Shoulder Left 3v Complete = Shoulder, Complete Left - 73030<\/option>\n<option value=\"Shoulder Right 2v AP&amp;LAT = Shoulder, Limited Right - 73020\">Shoulder Right 2v AP&amp;LAT = Shoulder, Limited Right - 73020<\/option>\n<option value=\"Shoulder Right 3v Complete = Shoulder, Complete Right - 73030\">Shoulder Right 3v Complete = Shoulder, Complete Right - 73030<\/option>\n<option value=\"Sinuses 2v Limited = Nasal Bones, limited - 70210\">Sinuses 2v Limited = Nasal Bones, limited - 70210<\/option>\n<option value=\"Skull, Limited 2v AP&amp;LAT = Skull, Limited - 70250\">Skull, Limited 2v AP&amp;LAT = Skull, Limited - 70250<\/option>\n<option value=\"Soft Tissue Axillary Left (Mass\/Lump\/Hematoma) ultrasound = Limited Breast ultrasound - 76604\">Soft Tissue Axillary Left (Mass\/Lump\/Hematoma) ultrasound = Limited Breast ultrasound - 76604<\/option>\n<option value=\"Soft Tissue Axillary Right (Mass\/Lump\/Hematoma) ultrasound = Limited Breast ultrasound - 76604\">Soft Tissue Axillary Right (Mass\/Lump\/Hematoma) ultrasound = Limited Breast ultrasound - 76604<\/option>\n<option value=\"Soft Tissue Back ultrasound = Back ultrasound - 76604\">Soft Tissue Back ultrasound = Back ultrasound - 76604<\/option>\n<option value=\"Soft Tissue Chest ultrasound = Chest ultrasound - 76604\">Soft Tissue Chest ultrasound = Chest ultrasound - 76604<\/option>\n<option value=\"Soft Tissue Head\/Neck ultrasound (Mass\/Lump\/Hematoma) = Soft Tissue, head\/neck thyroid - 76536\">Soft Tissue Head\/Neck ultrasound (Mass\/Lump\/Hematoma) = Soft Tissue, head\/neck thyroid - 76536<\/option>\n<option value=\"Soft Tissue Left Arm ultrasound (Mass\/lumps\/hematoma) = Soft Tissue extremity, non-vascular - 76881\">Soft Tissue Left Arm ultrasound (Mass\/lumps\/hematoma) = Soft Tissue extremity, non-vascular - 76881<\/option>\n<option value=\"Soft Tissue Left Leg ultrasound (Mass\/lumps\/hematoma) = Soft Tissue extremity, non-vascular - 76881\">Soft Tissue Left Leg ultrasound (Mass\/lumps\/hematoma) = Soft Tissue extremity, non-vascular - 76881<\/option>\n<option value=\"Soft Tissue Right Arm ultrasound (Mass\/lumps\/hematoma) = Soft Tissue extremity, non-vascular - 76881\">Soft Tissue Right Arm ultrasound (Mass\/lumps\/hematoma) = Soft Tissue extremity, non-vascular - 76881<\/option>\n<option value=\"Soft Tissue Right Leg ultrasound (Mass\/lumps\/hematoma) = Soft Tissue extremity, non-vascular - 76881\">Soft Tissue Right Leg ultrasound (Mass\/lumps\/hematoma) = Soft Tissue extremity, non-vascular - 76881<\/option>\n<option value=\"Testes\/Scrotum ultrasound= Echo, Scrotum &amp; Concepts - 76870\">Testes\/Scrotum ultrasound= Echo, Scrotum &amp; Concepts - 76870<\/option>\n<option value=\"Thoracic Spine, T Spine 2v AP&amp;LAT = Spine, Thoracic AP&amp;LAT - 72070\">Thoracic Spine, T Spine 2v AP&amp;LAT = Spine, Thoracic AP&amp;LAT - 72070<\/option>\n<option value=\"Thyroid ultrasound = Echo soft tissue, head\/neck thyroid - 76536\">Thyroid ultrasound = Echo soft tissue, head\/neck thyroid - 76536<\/option>\n<option value=\"Tib\/Fib Left 2v AP&amp;LAT = Tibia\/Fibula Left AP&amp;LAT - 73590\">Tib\/Fib Left 2v AP&amp;LAT = Tibia\/Fibula Left AP&amp;LAT - 73590<\/option>\n<option value=\"Tib\/Fib Right 2v AP&amp;LAT = Tibia\/Fibula Right AP&amp;LAT - 73590\">Tib\/Fib Right 2v AP&amp;LAT = Tibia\/Fibula Right AP&amp;LAT - 73590<\/option>\n<option value=\"Toes\/digits Left (1-5) 3v Complete = toes Left - 33660\">Toes\/digits Left (1-5) 3v Complete = toes Left - 33660<\/option>\n<option value=\"Toes\/digits Right (1-5) 3v Complete = toes Right - 73660\">Toes\/digits Right (1-5) 3v Complete = toes Right - 73660<\/option>\n<option value=\"Wrist Left 2v AP&amp;LAT = Wrist, AP&amp;LAT Left - 73100\">Wrist Left 2v AP&amp;LAT = Wrist, AP&amp;LAT Left - 73100<\/option>\n<option value=\"Wrist Left 3v Complete = Wrist, complete Left - 73110\">Wrist Left 3v Complete = Wrist, complete Left - 73110<\/option>\n<option value=\"Wrist Right 2v AP&amp;LAT = Wrist, AP&amp;LAT Right - 73100\">Wrist Right 2v AP&amp;LAT = Wrist, AP&amp;LAT Right - 73100<\/option>\n<option value=\"Wrist Right 3v Complete = Wrist, complete Right - 73110\">Wrist Right 3v Complete = Wrist, complete Right - 73110<\/option>\n<\/select>\n<\/span>\n<span class=\"bfElemWrap bfLabelLeft\" id=\"bfElemWrap324\">\n<label id=\"bfLabel324\" for=\"ff_elem324\">How Many Views<\/label>\n<input class=\"ff_elem\" style=\"width:100%\" type=\"text\" name=\"ff_nm_howmanyviews3[]\" value=\"\" id=\"ff_elem324\"\/>\n<\/span>\n<span class=\"bfElemWrap bfLabelLeft\" id=\"bfElemWrap343\">\n<label id=\"bfLabel343\" for=\"ff_elem343\">ICD-10 Code<\/label>\n<select class=\"ff_elem\" name=\"ff_nm_ICD10Code3[]\" id=\"ff_elem343\">\n<option value=\"\">PLEASE SELECT AN ICD-10 CODE<\/option>\n<option value=\"R76.11\">+PPD - R76.11<\/option>\n<option value=\"I71.4\">AAA W\/O RUPTURE - I71.4<\/option>\n<option value=\"R09.89\">ABN CHEST SOUNDS - R09.89<\/option>\n<option value=\"J81.0\">ACUTE PULMONARY EDEMA - J81.0<\/option>\n<option value=\"J80\">ACUTE RESPIRATORY DISTRESS SYNDROME - J80<\/option>\n<option value=\"I48.91\">AFIB - I48.91<\/option>\n<option value=\"M25.572\">ANKLE PAIN (LEFT) - M25.572<\/option>\n<option value=\"M25.571\">ANKLE PAIN (RIGHT) - M25.571<\/option>\n<option value=\"R001\">BRADYCARDIA (UNSPECIFIED) - R001<\/option>\n<option value=\"N63\">BREAST LUMP - N63<\/option>\n<option value=\"I25.10\">CAD - I25.10<\/option>\n<option value=\"R01.1\">CARDIAC MURMUR - R01.1<\/option>\n<option value=\"R09.89\">CAROTID BRUIT - R09.89<\/option>\n<option value=\"R07.9\">CHEST PAIN - R07.9<\/option>\n<option value=\"I50.9\">CHF - I50.9<\/option>\n<option value=\"R06.89\">CONGESTION - R06.89<\/option>\n<option value=\"K59.00\">CONSTIPATION (UNSPECIFIED) - K59.00<\/option>\n<option value=\"J44.1\">COPD - J44.1<\/option>\n<option value=\"R05\">COUGH - R05<\/option>\n<option value=\"R04.89\">COUGH W\/ HEMORRAGE - R04.89<\/option>\n<option value=\"M50.30\">DDD C SPINE - M50.30<\/option>\n<option value=\"M51.36\">DDD L SPINE - M51.36<\/option>\n<option value=\"M51.34\">DDD T SPINE - M51.34<\/option>\n<option value=\"R42\">DIZZINESS \/ GIDDINESS - R42<\/option>\n<option value=\"I82.402\">DVT (LEFT LOWER EXTREMITY) - I82.402<\/option>\n<option value=\"I82.622\">DVT (LEFT UPPER EXTREMITY) - I82.622<\/option>\n<option value=\"I82.401\">DVT (RIGHT LOWER EXTREMITY) - I82.401<\/option>\n<option value=\"I82.621\">DVT (RIGHT UPPER EXTREMITY) - I82.621<\/option>\n<option value=\"R06.09\">DYSPNEA - R06.09<\/option>\n<option value=\"R60.1\">EDEMA (GENERALIZED) - R60.1<\/option>\n<option value=\"R60.0\">EDEMA (LOCALIZED) - R60.0<\/option>\n<option value=\"M25.522\">ELBOW (LEFT) - M25.522<\/option>\n<option value=\"M25.521\">ELBOW (RIGHT) - M25.521<\/option>\n<option value=\"Z03.89\">ENCOUNTER FOR OBSERVATION FOR OTHER SUSPECTED DISEASES AND CONDITIONS RULED OUT - Z03.89<\/option>\n<option value=\"I10\">ESSENTIAL HYPERTENSION (PRIMARY) - I10<\/option>\n<option value=\"K56.49\">FECAL IMPACTION - K56.49<\/option>\n<option value=\"N94.89\">FEMALE GENITAL SYMPTOMS - N94.89<\/option>\n<option value=\"R50.9\">FEVER - R50.9<\/option>\n<option value=\"M79.645\">FINGER PAIN (LEFT) - M79.645<\/option>\n<option value=\"M79.644\">FINGER PAIN (RIGHT) - M79.644<\/option>\n<option value=\"M79.672\">FOOT PAIN (LEFT) - M79.672<\/option>\n<option value=\"M79.671\">FOOT PAIN (RIGHT) - M79.671<\/option>\n<option value=\"M79.632\">FOREARM (LEFT) - M79.632<\/option>\n<option value=\"M79.631\">FOREARM (RIGHT) - M79.631<\/option>\n<option value=\"Z43.1\">GASTROSTOMY ATTENTION ENCOUNTER - Z43.1<\/option>\n<option value=\"Z93.1\">GASTROSTOMY STATUS - Z93.1<\/option>\n<option value=\"E04.2\">GOITER - E04.2<\/option>\n<option value=\"M79.642\">HAND (LEFT) - M79.642<\/option>\n<option value=\"M79.641\">HAND (RIGHT) - M79.641<\/option>\n<option value=\"M25.552\">HIP PAIN (LEFT) - M25.552<\/option>\n<option value=\"M25.551\">HIP PAIN (RIGHT) - M25.551<\/option>\n<option value=\"N20.0\">KIDNEY CALCUNI - N20.0<\/option>\n<option value=\"M25.562\">KNEE PAIN (LEFT) - M25.562<\/option>\n<option value=\"M25.561\">KNEE PAIN (RIGHT) - M25.561<\/option>\n<option value=\"M54.5\">L SPINE - M54.5<\/option>\n<option value=\"R11.0\">NAUSEA - R11.0<\/option>\n<option value=\"R11.2\">NAUSEA W\/ VOMITING - R11.2<\/option>\n<option value=\"R00.8\">OTHER ABNORMALITIES OF HEART RATE - R00.8<\/option>\n<option value=\"K59.09\">OTHER CONSTIPATION - K59.09<\/option>\n<option value=\"R91.8\">OTHER NONSPECIFIC FINDINGS OF THE LUNG - R91.8<\/option>\n<option value=\"R10.13\">PAIN ABDOMINAL (EPIGASTRIC) - R10.13<\/option>\n<option value=\"R10.84\">PAIN ABDOMINAL (GENERAL) - R10.84<\/option>\n<option value=\"R10.32\">PAIN ABDOMINAL (LEFT LOWER QUADRANT) - R10.32<\/option>\n<option value=\"R10.12\">PAIN ABDOMINAL (LEFT UPPER QUADRANT) - R10.12<\/option>\n<option value=\"R10.31\">PAIN ABDOMINAL (RIGHT LOWER QUADRANT) - R10.31<\/option>\n<option value=\"R10.11\">PAIN ABDOMINAL (RIGHT UPPER QUADRANT) - R10.11<\/option>\n<option value=\"M54.2\">PAIN C SPINE - M54.2<\/option>\n<option value=\"M79.605\">PAIN IN LIMB (LEFT LOWER EXTREMITY) - M79.605<\/option>\n<option value=\"M79.602\">PAIN IN LIMB (LEFT UPPER EXTREMITY) - M79.602<\/option>\n<option value=\"M79.604\">PAIN IN LIMB (RIGHT LOWER EXTREMITY) - M79.604<\/option>\n<option value=\"M79.601\">PAIN IN LIMB (RIGHT UPPER EXTREMITY) - M79.601<\/option>\n<option value=\"Z45.09\">PICC LINE - Z45.09<\/option>\n<option value=\"J16.8\">PNUEMONIA (SPECIFIED ORGANISM) - J16.8<\/option>\n<option value=\"J18.9\">PNUEMONIA (UNSPECIFIED ORGANISM) - J18.9<\/option>\n<option value=\"I73.89\">PPD (OTHER SPECIFIED PERIPHERAL VASCULAR DISEASE) - I73.89<\/option>\n<option value=\"I73.9\">PPD (UNSPECIFIED) - I73.9<\/option>\n<option value=\"R07.2\">PRECORDIAL PAIN - R07.2<\/option>\n<option value=\"J84.10\">PULMONARY FIBROSIS - J84.10<\/option>\n<option value=\"R91.1\">PULMONARY NODULE - R91.1<\/option>\n<option value=\"J96.00\">RESPIRATORY FAILURE - J96.00<\/option>\n<option value=\"J96.90\">RESPIRATORY FAILURE (CHRONIC) - J96.90<\/option>\n<option value=\"M25.512\">SHOULDER PAIN (LEFT) - M25.512<\/option>\n<option value=\"M25.511\">SHOULDER PAIN (RIGHT) - M25.511<\/option>\n<option value=\"R06.02\">SOB - R06.02<\/option>\n<option value=\"R22.1\">SOFT TISSUE NECK LUMP - R22.1<\/option>\n<option value=\"I65.29\">STENOSIS CAROTID ARTERY - I65.29<\/option>\n<option value=\"R22.43\">SWELLING LIMB (BILATERAL LOWER EXTREMITY) - R22.43<\/option>\n<option value=\"R22.33\">SWELLING LIMB (BILATERAL UPPER EXTREMITY) - R22.33<\/option>\n<option value=\"R22.42\">SWELLING LIMB (LEFT LOWER EXTREMITY) - R22.42<\/option>\n<option value=\"R22.32\">SWELLING LIMB (LEFT UPPER EXTREMITY) - R22.32<\/option>\n<option value=\"R22.41\">SWELLING LIMB (RIGHT LOWER EXTREMITY) - R22.41<\/option>\n<option value=\"R22.31\">SWELLING LIMB (RIGHT UPPER EXTREMITY) - R22.31<\/option>\n<option value=\"R22.9\">SWELLING MASS LUMP (CHEST) - R22.9<\/option>\n<option value=\"R22.2\">SWELLING MASS LUMP (TRUNK) - R22.2<\/option>\n<option value=\"M54.6\">T SPINE - M54.6<\/option>\n<option value=\"R00.0\">TACHYCARDIA - R00.0<\/option>\n<option value=\"A15.0\">TB - A15.0<\/option>\n<option value=\"M79.652\">THIGH PAIN (LEFT) - M79.652<\/option>\n<option value=\"M79.651\">THIGH PAIN (RIGHT) - M79.651<\/option>\n<option value=\"E04.1\">THYROID NODULE - E04.1<\/option>\n<option value=\"M79.675\">TOES (LEFT) - M79.675<\/option>\n<option value=\"M79.674\">TOES (RIGHT) - M79.674<\/option>\n<option value=\"Z45.2\">VASCULAR ACCESS DEVICE ADJUSTMENT\/MANAGEMENT ENCOUNTER - Z45.2<\/option>\n<option value=\"R11.10\">VOMITING - R11.10<\/option>\n<option value=\"R11.12\">VOMITING (PROJECTILE) - R11.12<\/option>\n<option value=\"R11.11\">VOMITING W\/O NAUSEA - R11.11<\/option>\n<option value=\"R06.2\">WHEEZING - R06.2<\/option>\n<\/select>\n<\/span>\n<\/div>\n<\/div>\n<div class=\"bfNoSection\" id=\"row10\">\n<div class=\"bfClearfix\">\n<span class=\"bfElemWrap bfLabelLeft\" id=\"bfElemWrap229\">\n<label id=\"bfLabel229\" for=\"ff_elem229\"><span class=\"bfRequired\">*<\/span> \nCompleted By<\/label>\n<input class=\"ff_elem\" style=\"width:100%\" type=\"text\" name=\"ff_nm_completedby[]\" value=\"\" id=\"ff_elem229\"\/>\n<\/span>\n<span class=\"bfElemWrap bfLabelLeft\" id=\"bfElemWrap230\">\n<label id=\"bfLabel230\" for=\"ff_elem230\"><span class=\"bfRequired\">*<\/span> \nOrdering Physician (electronically authorized and signed by)<\/label>\n<input class=\"ff_elem\" style=\"width:100%\" type=\"text\" name=\"ff_nm_PhysiciansSignature[]\" value=\"\" id=\"ff_elem230\"\/>\n<\/span>\n<input class=\"ff_elem\" type=\"hidden\" name=\"ff_nm_submitted[]\" value=\"\" id=\"ff_elem231\"\/>\n<\/div>\n<\/div>\n<div class=\"bfNoSection\" id=\"row11\">\n<div class=\"bfClearfix\">\n<span class=\"bfElemWrap bfLabelLeft\" id=\"bfElemWrap232\">\n<label id=\"bfLabel232\" for=\"ff_elem232\"><span class=\"bfRequired\">*<\/span> \nFax Results TO<\/label>\n<input class=\"ff_elem\" style=\"width:100%\" type=\"text\" name=\"ff_nm_FaxResultsTO[]\" value=\"\" id=\"ff_elem232\"\/>\n<\/span>\n<span class=\"bfElemWrap bfLabelLeft\" id=\"bfElemWrap233\">\n<label id=\"bfLabel233\" for=\"ff_elem233\">Phone Results TO<\/label>\n<input class=\"ff_elem\" style=\"width:100%\" type=\"text\" name=\"ff_nm_PhoneResultsTO[]\" value=\"\" id=\"ff_elem233\"\/>\n<\/span>\n<\/div>\n<\/div>\n<div class=\"bfNoSection\" id=\"bfQuickModeSection35719\">\n<div class=\"bfClearfix\">\n<span class=\"bfElemWrap bfLabelLeft\" id=\"bfElemWrap234\">\n<label id=\"bfLabel234\" for=\"ff_elem234\">Comments <span class=\"bfMaxLengthCounter\" id=\"bfMaxLengthCounter234\">(75 chars left)<\/span><\/label>\n<textarea cols=\"20\" rows=\"5\" class=\"ff_elem\" onkeyup=\"bfCheckMaxlength(234, 75, true)\" name=\"ff_nm_comments[]\" id=\"ff_elem234\"><\/textarea>\n<\/span>\n<span class=\"bfElemWrap bfLabelLeft\" id=\"bfElemWrap235\">\n<label id=\"bfLabel235\" for=\"ff_elem235\">Attach File<\/label>\n<input class=\"ff_elem\" type=\"file\" name=\"ff_nm_attachfile[]\" id=\"ff_elem235\"\/>\n<span id=\"ff_elem235_files\"><\/span><\/span>\n<\/div>\n<\/div>\n<div class=\"bfNoSection\" id=\"row12\">\n<section class=\"bfSectionDescription\">\n<div class='time-frame'>\n    <div id='date-part'><\/div>\n    <div id='time-part'><\/div>\n<\/div>\n\n<\/section>\n<div class=\"bfClearfix\">\n<span class=\"bfElemWrap bfLabelLeft\" id=\"bfElemWrap236\">\n<label id=\"bfLabel236\" for=\"ff_elem236\">STAT<\/label>\n<input class=\"ff_elem\" type=\"checkbox\" name=\"ff_nm_stat[]\" value=\"Request is STAT\" id=\"ff_elem236\"\/>\n<\/span>\n<span class=\"bfElemWrap bfLabelLeft\" id=\"bfElemWrap1049\">\n<label id=\"bfLabel1049\" for=\"ff_elem1049\"><span id=\"bfTooltip1049\" class=\"bfTooltip\">&nbsp;<\/span>Same Day Service<\/label><script type=\"text\/javascript\"><!--\nJQuery(document).ready(function() {JQuery(\"#bfTooltip1049\").qtip({ position: { adjust: { screen: true } }, content: \"<div class=\\\"bfToolTipLabel\\\"><b>Same Day Service<\/b><div\/>Select this if you need results today.\",style: {tip: !JQuery.browser.ie, background: \"#ffc\", color: \"#000000\", border : { color: \"#C0C0C0\", width: 1 }, name: \"cream\" } });});\n\/\/--><\/script>\n<input class=\"ff_elem\" type=\"checkbox\" name=\"ff_nm_sameday[]\" value=\"Same day service\" id=\"ff_elem1049\"\/>\n<\/span>\n<span class=\"bfElemWrap bfLabelLeft\" id=\"bfElemWrap1086\">\n<label id=\"bfLabel1086\" for=\"ff_elem1086\"><span id=\"bfTooltip1086\" class=\"bfTooltip\">&nbsp;<\/span>Routine (noon tomorrow)<\/label><script type=\"text\/javascript\"><!--\nJQuery(document).ready(function() {JQuery(\"#bfTooltip1086\").qtip({ position: { adjust: { screen: true } }, content: \"<div class=\\\"bfToolTipLabel\\\"><b>Routine (noon tomorrow)<\/b><div\/>Select this to receive results by noon tomorrow.\",style: {tip: !JQuery.browser.ie, background: \"#ffc\", color: \"#000000\", border : { color: \"#C0C0C0\", width: 1 }, name: \"cream\" } });});\n\/\/--><\/script>\n<input class=\"ff_elem\" type=\"checkbox\" name=\"ff_nm_routine[]\" value=\"Routine timing\" id=\"ff_elem1086\"\/>\n<\/span>\n<div class=\"bfNoSection\" id=\"bfQuickModeSection24730\">\n<\/div>\n<input class=\"ff_elem\" type=\"hidden\" name=\"ff_nm_TimeStamp[]\" value=\"\" id=\"ff_elem838\"\/>\n<\/div>\n<\/div>\n<\/div>\n<div class=\"bfNoSection\" id=\"clinicalcondition\">\n<section class=\"bfElemWrap bfLabelLeft\" id=\"bfElemWrap1091\">\n<label id=\"bfLabel1091\" for=\"ff_elem1091\"><span class=\"bfRequired\">*<\/span> \n<span id=\"bfTooltip1091\" class=\"bfTooltip\">&nbsp;<\/span>Portable x-ray(s) are required because the patient is unable to travel to a physician's office or other outpatient radiology facility due to the following clinical condition:<\/label><script type=\"text\/javascript\"><!--\nJQuery(document).ready(function() {JQuery(\"#bfTooltip1091\").qtip({ position: { adjust: { screen: true } }, content: \"<div class=\\\"bfToolTipLabel\\\"><b>Portable x-ray(s) are required because the patient is unable to travel to a physician\\'s office or other outpatient radiology facility due to the following clinical condition:<\/b><div\/>The patient is unable to travel to a physician\\'s office or other outpatient radiology facility due to the following clinical condition.\",style: {tip: !JQuery.browser.ie, background: \"#ffc\", color: \"#000000\", border : { color: \"#C0C0C0\", width: 1 }, name: \"cream\" } });});\n\/\/--><\/script>\n<input class=\"ff_elem\" style=\"width:100%\" maxlength=\"100\" type=\"text\" name=\"ff_nm_condition[]\" value=\"\" id=\"ff_elem1091\"\/>\n<\/section>\n<\/div>\n<button id=\"bfSubmitButton\" class=\"bfSubmitButton\" type=\"submit\" onclick=\"if(document.getElementById('bfPaymentMethod')){document.getElementById('bfPaymentMethod').value='';};ff_validate_submit(this, 'click'); return false;\" value=\"submit\"><span>submit<\/span><\/button>\n<\/div>\n<noscript>Please turn on javascript to submit your data. Thank you!<\/noscript>\n  <link rel=\"stylesheet\" href=\"https:\/\/www.rapid-ray.com\/wp-content\/plugins\/breezing-forms\/platform\/\/media\/system\/css\/calendar-jos.css\" type=\"text\/css\"  title=\"Green\"  media=\"all\" \/>\n  <script src=\"https:\/\/www.rapid-ray.com\/wp-content\/plugins\/breezing-forms\/platform\/\/media\/system\/js\/mootools-core.js\" type=\"text\/javascript\"><\/script>\n  <script src=\"https:\/\/www.rapid-ray.com\/wp-content\/plugins\/breezing-forms\/platform\/\/media\/system\/js\/core.js\" type=\"text\/javascript\"><\/script>\n  <script src=\"https:\/\/www.rapid-ray.com\/wp-content\/plugins\/breezing-forms\/platform\/\/media\/system\/js\/mootools-more.js\" type=\"text\/javascript\"><\/script>\n  <script src=\"https:\/\/www.rapid-ray.com\/wp-content\/plugins\/breezing-forms\/platform\/\/media\/system\/js\/calendar.js\" type=\"text\/javascript\"><\/script>\n  <script src=\"https:\/\/www.rapid-ray.com\/wp-content\/plugins\/breezing-forms\/platform\/\/media\/system\/js\/calendar-setup.js\" type=\"text\/javascript\"><\/script>\n  <script type=\"text\/javascript\">\nCalendar._DN = new Array (\"Sunday\", \"Monday\", \"Tuesday\", \"Wednesday\", \"Thursday\", \"Friday\", \"Saturday\", \"Sunday\"); Calendar._SDN = new Array (\"Sun\", \"Mon\", \"Tue\", \"Wed\", \"Thu\", \"Fri\", \"Sat\", \"Sun\"); Calendar._FD = 0; Calendar._MN = new Array (\"January\", \"February\", \"March\", \"April\", \"May\", \"June\", \"July\", \"August\", \"September\", \"October\", \"November\", \"December\"); Calendar._SMN = new Array (\"Jan\", \"Feb\", \"Mar\", \"Apr\", \"May\", \"Jun\", \"Jul\", \"Aug\", \"Sep\", \"Oct\", \"Nov\", \"Dec\"); Calendar._TT = {};Calendar._TT[\"INFO\"] = \"About the Calendar\"; Calendar._TT[\"ABOUT\"] =\n \"DHTML Date\/Time Selector\\n\" +\n \"(c) dynarch.com 2002-2005 \/ Author: Mihai Bazon\\n\" +\n\"For latest version visit: http:\/\/www.dynarch.com\/projects\/calendar\/\\n\" +\n\"Distributed under GNU LGPL.  See http:\/\/gnu.org\/licenses\/lgpl.html for details.\" +\n\"\\n\\n\" +\n\"Date selection:\\n\" +\n\"- Use the \u00ab and \u00bb buttons to select year\\n\" +\n\"- Use the < and > buttons to select month\\n\" +\n\"- Hold mouse button on any of the above buttons for faster selection.\";\nCalendar._TT[\"ABOUT_TIME\"] = \"\\n\\n\" +\n\"Time selection:\\n\" +\n\"- Click on any of the time parts to increase it\\n\" +\n\"- or Shift-click to decrease it\\n\" +\n\"- or click and drag for faster selection.\";\n\n\t\tCalendar._TT[\"PREV_YEAR\"] = \"Click to move to the previous year. Click and hold for a list of years.\"; Calendar._TT[\"PREV_MONTH\"] = \"Click to move to the previous month. Click and hold for a list of the months.\"; Calendar._TT[\"GO_TODAY\"] = \"Go to today\"; Calendar._TT[\"NEXT_MONTH\"] = \"Click to move to the next month. Click and hold for a list of the months.\"; Calendar._TT[\"NEXT_YEAR\"] = \"Click to move to the next year. Click and hold for a list of years.\"; Calendar._TT[\"SEL_DATE\"] = \"Select a date.\"; Calendar._TT[\"DRAG_TO_MOVE\"] = \"Drag to move\"; Calendar._TT[\"PART_TODAY\"] = \"Today\"; Calendar._TT[\"DAY_FIRST\"] = \"Display %s first\"; Calendar._TT[\"WEEKEND\"] = \"0,6\"; Calendar._TT[\"CLOSE\"] = \"Close\"; Calendar._TT[\"TODAY\"] = \"Today\"; Calendar._TT[\"TIME_PART\"] = \"(Shift-)Click or Drag to change the value.\"; Calendar._TT[\"DEF_DATE_FORMAT\"] = \"%Y-%m-%d\"; Calendar._TT[\"TT_DATE_FORMAT\"] = \"%a, %b %e\"; Calendar._TT[\"WK\"] = \"wk\"; Calendar._TT[\"TIME\"] = \"Time:\";\n  <\/script>\n<style type=\"text\/css\">\n\n\n.bfClearfix:after {\ncontent: \".\";\ndisplay: block;\nheight: 0;\nclear: both;\nvisibility: hidden;\n}\n.bfInline{\nfloat:left;\n}\n.bfFadingClass{\ndisplay:none;\n}\n<\/style>\n<link rel=\"stylesheet\" href=\"https:\/\/www.rapid-ray.com\/wp-content\/plugins\/breezing-forms\/platform\/components\/com_breezingforms\/libraries\/jquery\/tooltip.css\" type=\"text\/css\" \/>\n<script type=\"text\/javascript\" src=\"https:\/\/www.rapid-ray.com\/wp-content\/plugins\/breezing-forms\/platform\/components\/com_breezingforms\/libraries\/jquery\/tooltip.js\"\/>\n<\/script>\n<script type=\"text\/javascript\"\/><!--\n\n\t\t\tfunction bfCheckMaxlength(id, maxlength, showMaxlength){\n\t\t\t\tif( JQuery(\"#ff_elem\"+id).val().length > maxlength ){\n\t\t\t\t\tJQuery(\"#ff_elem\"+id).val( JQuery(\"#ff_elem\"+id).val().substring(0, maxlength) );\n\t\t\t\t}\n\t\t\t\tif(showMaxlength){\n\t\t\t\t\tJQuery(\"#bfMaxLengthCounter\"+id).text( \"(\" + (maxlength - JQuery(\"#ff_elem\"+id).val().length) + \" chars left)\" );\n\t\t\t\t}\n\t\t\t}\n\t\t\tfunction bfRegisterSummarize(id, connectWith, type, emptyMessage, hideIfEmpty){\n\t\t\t\tbfSummarizers.push( { id : id, connectWith : connectWith, type : type, emptyMessage : emptyMessage, hideIfEmpty : hideIfEmpty } );\n\t\t\t}\n\t\t\tfunction bfField(name){\n\t\t\t\tvar value = \"\";\n\t\t\t\tswitch(ff_getElementByName(name).type){\n\t\t\t\t\tcase \"radio\":\n\t\t\t\t\t\tif(JQuery(\"[name=\"+ff_getElementByName(name).name+\"]:checked\").val() != \"\" && typeof JQuery(\"[name=\"+ff_getElementByName(name).name+\"]:checked\").val() != \"undefined\"){\n\t\t\t\t\t\t\tvalue = JQuery(\"[name=\"+ff_getElementByName(name).name+\"]:checked\").val();\n\t\t\t\t\t\t\tif(!isNaN(value)){\n\t\t\t\t\t\t\t\tvalue = Number(value);\n\t\t\t\t\t\t\t}\n\t\t\t\t\t\t}\n\t\t\t\t\t\tbreak;\n\t\t\t\t\tcase \"checkbox\":\n\t\t\t\t\tcase \"select-one\":\n\t\t\t\t\tcase \"select-multiple\":\n\t\t\t\t\t\tvar nodeList = document[\"ff_form2\"][\"\"+ff_getElementByName(name).name+\"\"];\n\t\t\t\t\t\tif(ff_getElementByName(name).type == \"checkbox\" && typeof nodeList.length == \"undefined\"){\n\t\t\t\t\t\t\tif(typeof JQuery(\"[name=\"+ff_getElementByName(name).name+\"]:checked\").val() != \"undefined\"){\n\t\t\t\t\t\t\t\tvalue = JQuery(\"[name=\"+ff_getElementByName(name).name+\"]:checked\").val();\n\t\t\t\t\t\t\t\tif(!isNaN(value)){\n\t\t\t\t\t\t\t\t\tvalue = Number(value);\n\t\t\t\t\t\t\t\t}\n\t\t\t\t\t\t\t}\n\t\t\t\t\t\t} else {\n\t\t\t\t\t\t\tvar val = \"\";\n\t\t\t\t\t\t\tfor(var j = 0; j < nodeList.length; j++){\n\t\t\t\t\t\t\t\tif(nodeList[j].checked || nodeList[j].selected){\n\t\t\t\t\t\t\t\t\tval += nodeList[j].value + \", \";\n\t\t\t\t\t\t\t\t}\n\t\t\t\t\t\t\t}\n\t\t\t\t\t\t\tif(val != \"\"){\n\t\t\t\t\t\t\t\tvalue = val.substr(0, val.length - 2);\n\t\t\t\t\t\t\t\tif(!isNaN(value)){\n\t\t\t\t\t\t\t\t\tvalue = Number(value);\n\t\t\t\t\t\t\t\t}\n\t\t\t\t\t\t\t}\n\t\t\t\t\t\t}\n\t\t\t\t\t\tbreak;\n\t\t\t\t\tdefault:\n\t\t\t\t\t\tif(!isNaN(ff_getElementByName(name).value)){\n\t\t\t\t\t\t\tvalue = Number(ff_getElementByName(name).value);\n\t\t\t\t\t\t} else {\n\t\t\t\t\t\t\tvalue = ff_getElementByName(name).value;\n\t\t\t\t\t\t}\n\t\t\t\t}\n\t\t\t\treturn value;\n\t\t\t}\n\t\t\tfunction populateSummarizers(){\n\t\t\t\t\/\/ cleaning first\n                                \n\t\t\t\tfor(var i = 0; i < bfSummarizers.length; i++){\n\t\t\t\t\tJQuery(\"#\"+bfSummarizers[i].id).parent().css(\"display\", \"\");\n\t\t\t\t\tJQuery(\"#\"+bfSummarizers[i].id).html(\"<span class=\\\"bfNotAvailable\\\">\"+bfSummarizers[i].emptyMessage+\"<\/span>\");\n\t\t\t\t}\n\t\t\t\tfor(var i = 0; i < bfSummarizers.length; i++){\n\t\t\t\t\tvar summVal = \"\";\n\t\t\t\t\tswitch(bfSummarizers[i].type){\n\t\t\t\t\t\tcase \"bfTextfield\":\n\t\t\t\t\t\tcase \"bfTextarea\":\n\t\t\t\t\t\tcase \"bfHidden\":\n\t\t\t\t\t\tcase \"bfCalendar\":\n\t\t\t\t\t\tcase \"bfFile\":\n\t\t\t\t\t\t\tif(JQuery(\"[name=\\\"ff_nm_\"+bfSummarizers[i].connectWith+\"[]\\\"]\").val() != \"\"){\n\t\t\t\t\t\t\t\tJQuery(\"#\"+bfSummarizers[i].id).text( JQuery(\"[name=\\\"ff_nm_\"+bfSummarizers[i].connectWith+\"[]\\\"]\").val() ).html();\n\t\t\t\t\t\t\t\tvar breakableText = JQuery(\"#\"+bfSummarizers[i].id).html().replace(\/\\r\/g, \"\").replace(\/\\n\/g, \"<br\/>\");\n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\tif(breakableText != \"\"){\n\t\t\t\t\t\t\t\t\tvar calc = null;\n\t\t\t\t\t\t\t\t\teval( \"calc = typeof bfFieldCalc\"+bfSummarizers[i].id+\" != \\\"undefined\\\" ? bfFieldCalc\"+bfSummarizers[i].id+\" : null\" );\n\t\t\t\t\t\t\t\t\tif(calc){\n\t\t\t\t\t\t\t\t\t\tbreakableText = calc(breakableText);\n\t\t\t\t\t\t\t\t\t}\n\t\t\t\t\t\t\t\t}\n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\tJQuery(\"#\"+bfSummarizers[i].id).html(breakableText);\n\t\t\t\t\t\t\t\tsummVal = breakableText;\n\t\t\t\t\t\t\t}\n\t\t\t\t\t\tbreak;\n\t\t\t\t\t\tcase \"bfRadioGroup\":\n\t\t\t\t\t\tcase \"bfCheckbox\":\n\t\t\t\t\t\t\tif(JQuery(\"[name=\\\"ff_nm_\"+bfSummarizers[i].connectWith+\"[]\\\"]:checked\").val() != \"\" && typeof JQuery(\"[name=\\\"ff_nm_\"+bfSummarizers[i].connectWith+\"[]\\\"]:checked\").val() != \"undefined\"){\n\t\t\t\t\t\t\t\tvar theText = JQuery(\"[name=\\\"ff_nm_\"+bfSummarizers[i].connectWith+\"[]\\\"]:checked\").val();\n\t\t\t\t\t\t\t\tif(theText != \"\"){\n\t\t\t\t\t\t\t\t\tvar calc = null;\n\t\t\t\t\t\t\t\t\teval( \"calc = typeof bfFieldCalc\"+bfSummarizers[i].id+\" != \\\"undefined\\\" ? bfFieldCalc\"+bfSummarizers[i].id+\" : null\" );\n\t\t\t\t\t\t\t\t\tif(calc){\n\t\t\t\t\t\t\t\t\t\ttheText = calc(theText);\n\t\t\t\t\t\t\t\t\t}\n\t\t\t\t\t\t\t\t}\n\t\t\t\t\t\t\t\tJQuery(\"#\"+bfSummarizers[i].id).text( theText );\n\t\t\t\t\t\t\t\tsummVal = theText;\n\t\t\t\t\t\t\t}\n\t\t\t\t\t\tbreak;\n\t\t\t\t\t\tcase \"bfCheckboxGroup\":\n\t\t\t\t\t\tcase \"bfSelect\":\n\t\t\t\t\t\t\tvar val = \"\";\n\t\t\t\t\t\t\tvar nodeList = document[\"ff_form2\"][\"ff_nm_\"+bfSummarizers[i].connectWith+\"[]\"];\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\tfor(var j = 0; j < nodeList.length; j++){\n\t\t\t\t\t\t\t\tif(nodeList[j].checked || nodeList[j].selected){\n\t\t\t\t\t\t\t\t\tval += nodeList[j].value + \", \";\n\t\t\t\t\t\t\t\t}\n\t\t\t\t\t\t\t}\n\t\t\t\t\t\t\tif(val != \"\"){\n\t\t\t\t\t\t\t\tvar theText = val.substr(0, val.length - 2);\n\t\t\t\t\t\t\t\tif(theText != \"\"){\n\t\t\t\t\t\t\t\t\tvar calc = null;\n\t\t\t\t\t\t\t\t\teval( \"calc = typeof bfFieldCalc\"+bfSummarizers[i].id+\" != \\\"undefined\\\" ? bfFieldCalc\"+bfSummarizers[i].id+\" : null\" );\n\t\t\t\t\t\t\t\t\tif(calc){\n\t\t\t\t\t\t\t\t\t\ttheText = calc(theText);\n\t\t\t\t\t\t\t\t\t}\n\t\t\t\t\t\t\t\t}\n\t\t\t\t\t\t\t\tJQuery(\"#\"+bfSummarizers[i].id).text( theText );\n\t\t\t\t\t\t\t\tsummVal = theText;\n\t\t\t\t\t\t\t}\n\t\t\t\t\t\tbreak;\n\t\t\t\t\t}\n\t\t\t\t\t\n\t\t\t\t\tif( ( bfSummarizers[i].hideIfEmpty && summVal == \"\" ) || ( typeof bfDeactivateField != \"undefined\" && bfDeactivateField[\"ff_nm_\"+bfSummarizers[i].connectWith+\"[]\"] ) ){\n                                            JQuery(\"#\"+bfSummarizers[i].id).parent().css(\"display\", \"none\");\n\t\t\t\t\t}\n\t\t\t\t}\n\t\t\t}\n\n\/\/--><\/script>\n<script type=\"text\/javascript\"\/><!--\nvar bfUseErrorAlerts = false;\n\n\/\/--><\/script>\n<script type=\"text\/javascript\"\/><!--\n\n\t\t\t\tfunction bfShowErrors(error){\n                                        JQuery(\".bfErrorMessage\").html(\"\");\n\t\t\t\t\tJQuery(\".bfErrorMessage\").css(\"display\",\"none\");\n\t\t\t\t\tJQuery(\".bfErrorMessage\").fadeIn(1500);\n\t\t\t\t\tvar allErrors = \"\";\n\t\t\t\t\tvar errors = error.split(\"\\n\");\n\t\t\t\t\tfor(var i = 0; i < errors.length; i++){\n\t\t\t\t\t\tallErrors += \"<div class=\\\"bfError\\\">\" + errors[i] + \"<\/div>\";\n\t\t\t\t\t}\n\t\t\t\t\tJQuery(\".bfErrorMessage\").html(allErrors);\n\t\t\t\t\tJQuery(\".bfErrorMessage\").css(\"display\",\"\");\n\n                                        if(JQuery.bfvalidationEngine)\n                                        {\n                                            JQuery(\"#ff_form2\").bfvalidationEngine({\n        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JQuery.bfvalidationEngine.closePrompt(\"#\"+ff_getElementByName(inlineErrorElements[i][0]).id);\n                                                    }\n                                                }\n                                            }\n                                            inlineErrorElements = new Array();\n                                        }\n\t\t\t\t}\n\/\/--><\/script>\n<script type=\"text\/javascript\"\/><!--\n\n\t\t\t\t\tvar bfElemWrapBg = \"\";\n\t\t\t\t\tfunction bfSetElemWrapBg(){\n\t\t\t\t\t\tbfElemWrapBg = JQuery(\".bfElemWrap\").css(\"background-color\");\n\t\t\t\t\t}\n\t\t\t\t\tfunction bfRollover() {\n\t\t\t\t\t\tJQuery(\".ff_elem\").focus(\n\t\t\t\t\t\t\tfunction(){\n\t\t\t\t\t\t\t\tvar parent = JQuery(this).parent();\n\t\t\t\t\t\t\t\tif(parent && parent.attr(\"class\").substr(0, 10) == \"bfElemWrap\"){\n\t\t\t\t\t\t\t\t\tparent.css(\"background\",\"#ffc\");\n\t\t\t\t\t\t\t\t} else {\n\t\t\t\t\t\t\t\t\tparent = 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Need this order STAT?\u00a0 Please call us at 520.881.2770 after you submit your order. If exam is needed same day, please call in orders after normal office hours.\u00a0 Our office hours are Monday thru [&hellip;]<\/p>\n","protected":false},"author":4,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_et_pb_use_builder":"on","_et_pb_old_content":"<style>\r\nbutton {<br \/>font-size: 18px;<br \/>font-weight: bold;<br \/>color: #444444;<br \/>font-family: \"Helvetica Neue\",Helvetica,Arial,Sans-serif;<br \/>}<br \/><\/style>\r\n<ul>\r\n \t<li><span style=\"color: #ff0000;\">Need this order STAT?\u00a0 Please call us<strong> at 520.881.2770<\/strong> after you submit your order.<\/span><\/li>\r\n \t<li><strong>If exam is needed same day, please call in orders after normal office hours.\u00a0 Our office hours are Monday thru Friday, 8am to 4pm.<\/strong><\/li>\r\n \t<li><strong>Questions?\u00a0 Call our Tucson office at 520.881.2770.<\/strong><\/li>\r\n \t<li>Fill out the online form below and click \"Submit\".\u00a0 Your information is secure and HIPAA compliant.<\/li>\r\n \t<li>To save a copy of your requested information, click the \"Generate PDF\" button at the bottom of the form BEFORE you click the submit button.<\/li>\r\n<\/ul>\r\n<a href=\"https:\/\/www.rapid-ray.com\/wp-content\/uploads\/2020\/01\/print-blank-2020-pdf.pdf\" target=\"_blank\" rel=\"noopener noreferrer\"><button type=\"button\">Print Blank Form<\/button><\/a>\r\n[breezingforms name=\"ReqTucson_revised\"]\r\n<h3>Optional - Save and Print Form Information Above:<\/h3>\r\n<strong>CHROME BROWSER REQUIRED for this functionality.\u00a0 Follow these steps BEFORE you click the \"SUBMIT\" button above.<\/strong>\u00a0 You will not be able to save your information after your order has been submitted to us.\r\n<ol>\r\n \t<li>After you click the \"Generate PDF\" button, your information above will be processed into a PDF document.<\/li>\r\n \t<li>When you see the \"Print PDF\" button appear below, your document is finished.<\/li>\r\n \t<li>Click \"Print PDF\" to open or download your document.<\/li>\r\n \t<li><strong>When finished, click the \"SUBMIT\" button above to send your information to us<\/strong>. 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