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  
L R X-ray C P T  
L R X-ray C P T  
L R
C o des C o des C o des
 
o Abdomen KUB 74000 N/A N/A o Finger/Phalanx (AP, LAT)
  o Orbits 70200 N/A N/A
73140
  o Abdomen 2 view s 74010 N/A N/A _______________________ o Paranasal Sinuses
70220 N/A N/A
  o Abdomen 3+ view s 74020 N/A N/A o Foot (AP, LAT, OBL) complete
73630
  o Abdomen obstruction o WB o Paranasal Sinuses limited 70210 N/A N/A
74022 N/A N/A
  series w /PA chest
o Forearm/radius&ulna o Pelvis (AP) 72170 N/A N/A
73090
  o Acetabulum (AP, Judet =
(AP, LAT)
o Pelvis adolescent/infant
  73050 71100 N/A N/A
45 degree obliques) o Hand (AP, LAT, OBL) 73130 (AP, Frog Leg)
  o Acromioclavicular joint 73050     o Heel/Calcaneus (AP, o Rib Unilateral 71100
  LAT)
73650
o Ankle (AP, LAT, Mortise) o Rib Unilateral w /PA
  73610
chest
71101
o WB
  o Hip OA/pre-op THA/new
o Bone Age Study 77072 N/A N/A fx (AP Pelvis & AP, Cross- 73100 o Ribs Bilateral w /PA
71111 N/A N/A
o Bone Length Study 77073 N/A N/A table LAT of hip) chest

o Cervical Spine 2-3 view s 72040 N/A N/A

o Hip follow -up THA or fx o Sacroiliac joints 72202 N/A N/A
(AP, Cross-table LAT of 74410 o Sacrum & Coccyx 72220 N/A N/A
o Cervical Spine (AP,
Lateral-Flexion & Extension, 72050 N/A N/A hip) o Scaphoid (ulnar deviated
Open Mouth, Obliques) AP = "scaphoid view ")
o Humerus (AP, LAT) 73060
o Cervical Spine w /flex/ext 72052 N/A N/A o Knee (AP, LAT, Sunrise) o Scapula 73010
73560
o Chest 1 view 71010 N/A N/A o WB o Scoliosis (Standing AP,
72069 N/A N/A
o Chest 2 view s 71020 N/A N/A o Knee (AP, LAT, Sunrise) LAT, Bending)
73560
o Chest 4+ view s 71030 N/A N/A o WB o Skull 70260 N/A N/A

o Clavicle (AP, 20 degree o Knee OA (Standing B/L o Skull limited 70250 N/A N/A
73562
Cephalic Axial View ) 73000 AP, LAT
o Shoulder (AP, Scapular
73030
o WB o NWB "Y", Axillary)
o Knee OA (Standing B/L
o Elbow 2 view s 73070 PA w ith 20 degrees of 73564 o Sternum (AP, LAT) 71120 N/A N/A
flexion, LAT, Sunrise)
o Elbow (AP, LAT, OBL; o S.C. Joints
71130
children <12 get comparison 73080 o Lumbar Spine 2-3 view s 72100 N/A N/A (sternoclavicular)
series)
o Lumbar Spine (AP, LAT, o Thoracic Spine (AP, LAT) 72070 N/A N/A
Obliques, Spot Lateral L5- 72110 N/A N/A o Tibia & Fibula (AP, LAT) 73590
o Elbow : Supracondylar fx
(AP, LAT 1/3 Distal 73080 S1)
o Tibia Plateau (AP, LAT, 2
Humerus) N/A N/A Oblique view s)
o Lumbar Spine flex/ext 72114
o Facial Bones 70150 o Mandible 70110 N/A N/A o Toes (AP, LAT, OBL) 73660
o Nasal bones 70160 N/A N/A o Wrist (Anatomical AP &
o Femur (AP, LAT) 73550 73110
o Neck Soft Tissue 70360 N/A N/A LAT tilt view s)

Comments/Other: o Wrist ORIF (Anatomical

AP & LAT tilt view s, 73110
oblique)

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