Radiology Department Radiology Diagnostic Requisition Order Date: Ordering Physician: Diagnosis/Symptoms: Patient Name: Appt Date: D.O.B. Precert Number Appt Time: CHEST & ABDOMEN Wrist Right AP LAT 73100 Lower EXT (L) INFANT 2 Views 73592 Scapula Left Complete 73010 Lower EXT (R) INFANT 2 Views 73592 73592 (PEG) Tubes Injection ABD Acute W CXR 3 Views ABD Flat W Upright or Decub 76080-49465 74022 74020 Scapula Right Complete Shoulder Left Min 2 Views 73010 73030 Lower EXT Bilat INFANT ABD KUB Chest PA LAT 2 Views Chest PA 1 View Sterno Clav Joint Min 3 Views XR Sternum 2 Views Ribs Bil 3 Views 74000 71020 71010 71130 71120 71110 Shoulder Right Min 2 Views SI Joints Min 3 Views Upper EXT (L) INFANT 2 View Upper EXT (R) INFANT 2 View Upper EXT Bilat INFANT 73030 72202 73592 73592 73592 Skull Min 4 Views Mandible Min 4 Views Facial Bones Min 3 Views Nasal Bone Min 3 Views Sinus Min 3 Views Neck Soft Tissue 70260 70100 70140 70160 70220 70360 Ribs Bil w/ PA CXR 4 Views Ribs Left 2 Views Ribs Left w/ PA CXR 71101 71100 71101 Ankle Left 3 Views Ankle Left AP LAT Ankle Right 3 Views 73610 73600 73610 Orbit Bilat Min 4 Views TM Joint BILAT 70200 70328 Ribs Right 2 Views Ribs Right w/ PA CXR 71100 71101 Ankle Right AP LAT Calcaneous Left AP LAT Calcaneous Right AP LAT 73600 73650 73650 Cervical Spine W Obliques Cervical Spine W Flex Ext Cervical Spine 2 or 3 Views 72050 72052 72040 Arthrogram Shoulder Injection AC Joints BIL W/WO Weights Clavicle Left Complete Clavicle Right Complete Elbow Left AP LAT Elbow Left Min 3 Views Elbow Right AP LAT Elbow Right Min 3 Views 23350 73050 73000 73000 73070 73080 73070 73080 Foot Left 3 Views Foot Left AP LAT Foot Right 3 Views Foot Right AP LAT Toe Right, Left, Bilat 1 2 3 4 5 Tibula Fibula Left 2 Views Tibula Fibula Right 2 Views Knee Bil Standing AP PA Only 73630 73620 73630 73620 73660 73590 73590 73565 Lumbar Spine 2 or 3 Views Lumbar Spine AP LAT Obliques Thoracic Spine Min 3 Views Thoracolumbar Spine 2 Views Scoliosis Survey Pelvis AP Sacrum Coccyx Min 2 Views 72100 72110 72072 72080 72090 72170 72220 Forearm Left AP LAT Forearm Right AP LAT Humerus Left 2 Views Humerus Right 2 Views Hand Left 2 Views Hand Left 3 Views Hand Right 2 Views Hand Right 3 Views Finger Right, Left, Bilat 1 2 3 4 5 Wrist Left 3 Views Wrist Left AP LAT Wrist Right 3 Views 73090 73090 73060 73060 73120 73130 73120 73130 73140 73110 73100 73110 Knee Left 4 Views Knee Right 4 Views Knee Left 3 Views Knee Right 3 Views Knee Left AP LAT Knee Right AP LAT Arthrogram Knee Injection Femur Left AP LAT Femur Right AP LAT Hip Left Min 2 Views Hip Right Min 2 Views Arthrogram Hip Injection 73564 73564 73562 73562 73560 73560 27370 73550 73550 73510 73510 27093 Mod Barium Swallow w Therapy Barium Swallow Barium Enema Air Contrast IVP GI Air Contrast UGI GI SBFT Small Bowel Series Hysterosalpingogram UPPER EXTREMITIES Emanuel Medical Center 117 Kite Road Swainsboro, GA 30401 Office (478)289-1285 Fax (478)289-1289 LOWER EXTREMITIES HEAD & NECK SPINE & PELVIS FLUORO EXAMS 74230 74220 74280 74400 74241 74249 74250 74740 BONE/JOINT STUDIES Bone Survey Bone Age XR Bone Length Study Physician Signature _____________________________________ 77075 77072 77073
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