TCRHCC Patient Label/Stamp X-­‐Ray Order Form Please see our website: http://tchealth.org/imaging_study/ for Secondary Order Forms, Patient Instructions, and other items to submit. X-ray
C P T C o des
o Abdomen KUB
74000
N/A N/A o Finger/Phalanx (AP, LAT)
o Abdomen 2 view s
74010
N/A N/A _______________________
o Abdomen 3+ view s
74020
N/A N/A o Foot (AP, LAT, OBL)
o Abdomen obstruction
series w /PA chest
74022
o Acetabulum (AP, Judet =
45 degree obliques)
73050
o Acromioclavicular joint
73050
o Ankle (AP, LAT, Mortise)
o WB
L
R
N/A N/A
X-ray
o WB
N/A N/A
o Cervical Spine (AP,
Lateral-Flexion & Extension,
Open Mouth, Obliques)
72050
o Cervical Spine w /flex/ext
72052
N/A N/A o Knee (AP, LAT, Sunrise)
o Chest 1 view
71010
N/A N/A
o Chest 2 view s
71020
N/A N/A o Knee (AP, LAT, Sunrise)
o Chest 4+ view s
71030
N/A N/A
o WB
o Paranasal Sinuses limited
70210
N/A N/A
o Pelvis (AP)
72170
N/A N/A
o Pelvis adolescent/infant
(AP, Frog Leg)
71100
N/A N/A
o Rib Unilateral
71100
o Rib Unilateral w /PA
chest
71101
o Ribs Bilateral w /PA
chest
71111
N/A N/A
o Sacroiliac joints
72202
N/A N/A
74410
o Sacrum & Coccyx
72220
N/A N/A
73060
o Scaphoid (ulnar deviated
AP = "scaphoid view ")
73630
73610
72040
o Hip follow -up THA or fx
(AP, Cross-table LAT of
N/A N/A hip)
o Humerus (AP, LAT)
73000
o NWB
o WB
o WB
o Knee OA (Standing B/L
AP, LAT
73100
73560
73560
73562
o Scapula
73010
o Scoliosis (Standing AP,
LAT, Bending)
72069
N/A N/A
o Skull
70260
N/A N/A
o Skull limited
70250
N/A N/A
o Shoulder (AP, Scapular
"Y", Axillary)
73030
o Sternum (AP, LAT)
71120
o Knee OA (Standing B/L
PA w ith 20 degrees of
flexion, LAT, Sunrise)
73564
73080
o Lumbar Spine 2-3 view s
72100
o Elbow : Supracondylar fx
(AP, LAT 1/3 Distal
Humerus)
72110
N/A N/A o Tibia & Fibula (AP, LAT)
73080
o Lumbar Spine (AP, LAT,
Obliques, Spot Lateral L5S1)
o Lumbar Spine flex/ext
72114
o Tibia Plateau (AP, LAT, 2
N/A N/A Oblique view s)
o Facial Bones
70150
o Mandible
70110
N/A N/A o Toes (AP, LAT, OBL)
73660
o Femur (AP, LAT)
73550
o Nasal bones
70160
o Neck Soft Tissue
70360
N/A N/A o Wrist (Anatomical AP &
N/A N/A LAT tilt view s)
73110
o Wrist ORIF (Anatomical
AP & LAT tilt view s,
oblique)
73110
o Elbow 2 view s
73070
o Elbow (AP, LAT, OBL;
children <12 get comparison
series)
Comments/Other:
R
N/A N/A
73650
o Cervical Spine 2-3 view s
L
70220
o Heel/Calcaneus (AP,
LAT)
77073
C P T C o des
o Paranasal Sinuses
complete
73130
77072
X-ray
N/A N/A
o Hand (AP, LAT, OBL)
o Bone Length Study
R
70200
73090
o Bone Age Study
L
o Orbits
73140
o Forearm/radius&ulna
(AP, LAT)
o Hip OA/pre-op THA/new
N/A N/A fx (AP Pelvis & AP, CrossN/A N/A table LAT of hip)
o Clavicle (AP, 20 degree
Cephalic Axial View )
C P T C o des
o S.C. Joints
N/A N/A (sternoclavicular)
o Thoracic Spine (AP, LAT)
Scheduling Phone: 928-­‐283-­‐1445 • Scheduling Fax: 928-­‐283-­‐1447 N/A N/A
71130
72070
73590
N/A N/A