WICE

Diagnostic imaging order form

DATE: / /

2500 w. layton ave. ste 20 milwaukee. wi 53221 • phone: (262) 261-9423 • fax: (414) 539-4185

Patients name phone# ()- dob: / /

reason icd9/10 code:

phys. phone# ()- ( FOR STAT AND AFTER HOUR READS )

phys. printed phys. sign:

PRIOR AUTH#: VALID DATES: / / TO / /

CT

head
Without Contrast 70450
With Contrast 70460
With & Without Contrast 70470

orbits/sella/post fossa/iac
Without Contrast 70480
With Contrast 70481
With & Without Contrast 70482

maxillofacial/sinus
Without Contrast 70486
With Contrast 70487
With & Without Contrast 70488

soft tissue neck
Without Contrast 70490
With Contrast 70491
With & Without Contrast 70492

cervical spine
Without Contrast 72125
With Contrast 72126
With & Without Contrast 72127

thoracic spine
Without Contrast 72128
With Contrast 72129
With & Without Contrast 72130

lumbar spine
Without Contrast 72131
With Contrast 72132
With & Without Contrast 72133

chest
Without Contrast 71250
With Contrast 71260
With & Without Contrast 71270

abdomen
Without Contrast 74150
With Contrast 74160
With & Without Contrast 74170

pelvis
Without Contrast 72192
With Contrast 72193
With & Without Contrast 72194

abdomen & pelvis
Without Contrast 74176
With Contrast 74177
With & Without Contrast 74178
Renal Stone 74176
Urogram 74178

lower extremity R L
Without Contrast 73700
With Contrast 73701
With & Without Contrast 73702

upper extremity R L
Without Contrast 73200
With Contrast 73201
With & Without Contrast 73202

CTA / CTV

HEAD / COW 70496
NECK / CAROTID 70498
THORACIC / PE CHEST 71275
ABDOMEN / AAA 74175
PELVIS 72191
ABDOMEN & PELVIS 74174
ABD/PEL WITH RUNOFF 75635
VENOGRAM ABD/PEL 74174

MRI

brain
Without Contrast 70551
With & Without Contrast 70553

tmj
Without Contrast 70336

orbit / face /neck
Without Contrast 70540
With & Without Contrast 70543

upper extremity non joint R L
HUMERUS RADIUS/ULNA HAND
Without Contrast 73218
With & Without Contrast 73220

upper extremity joint R L
SHOULDER ELBOW WRIST
Without Contrast 73221
With & Without Contrast 73223

chest
Without Contrast 71550
With & Without Contrast 71552

abdomen
Without Contrast 74181
With & Without Contrast 74183

pelvis
Without Contrast 72195
With & Without Contrast 72197

cervical spine
Without Contrast 72141
With & Without Contrast 72156

thoracic spine
Without Contrast 72146
With & Without Contrast 72157

lumbar spine
Without Contrast 72148
With & Without Contrast 72158

lower extremity non joint R L
FEMUR TIB/FIB MIDFOOT FOREFOOT
Without Contrast 73718
With & Without Contrast 73720

lower extremity joint R L
HIP KNEE ANKLE HINDFOOT/HEEL
Without Contrast 73721
With & Without Contrast 73723

Patients name phone# ()- dob: / /

MRA MRV

head / brain
Without Contrast 70544
With & Without Contrast 70546

carotid / soft tissue neck
Without Contrast 70547
With & Without Contrast 70549

upper extremity R L
With & Without Contrast 73225

chest
With & Without Contrast 71555

pelvis
With & Without Contrast 72198

abdomen / renal
With & Without Contrast 74185

runoff / lower extremity R L
With or Without Contrast 74185

XRAY

abdomen
AP / KUB 1 View 74018
2 Views 74019
3 Views / Obliques 74021

ANKLE R L
2 View 73600
3 View 73610

Chest
1 View 71045
2 Views 71046
3 Views / Obliques 71047

CLAVICLE R L
1 View 73000

ELBOW R L
2 View 73070
3 View 73080

FACIAL BONES
3 Views 70140
Complete 70150

FEMUR R L
2 View 73552

FOOT R L
2 View 73620
3 View 73630
Weight Bearing

FOREARM R L
2 View 73090

HAND R L
2 View 73120
3 View 73130

HEEL R L
2 View 73650

HIP R L
2-3 View Unilateral 73502

HUMERUS R L
2 View 73060

KNEE R L
1-2 View 73560
3 View 73562
Bilateral Standing 73565

MANDIBLE
< 4 View 70100
4 View 70110

NASAL BONE
3 View 70160

ORBITS
4 View 70200
Foreign Body (pre MR) 70030

PELVIS
1-2 View 72170
3 View 72190

RIBS R L
Unilateral 2 View 71100
Unilateral w/Chest 3 View 71101
Bilateral 3 View 71110
Bilateral w/Chest 4 View 71111

SI JOINT
< 3 View 72200
3 View 72202

SACRUM / COCCYX
2 View 72220

SC JOINTS
3 View 71130

SCAPULA R L
Complete 73010

SHOULDER R L
2 View 73030
AC Joints 73050

SINUSES
< 3 View 70210
3 View 70220

SKULL
< 4 View 70250
4 View 70260

SOFT TISSUE NECK
2 View 70360

CERVICAL SPINE
2-3 View 72040
AP, Lat & Obl 4-5 View 72050
Flex & Ext / 5+ Views 72052

THORACIC SPINE
2 View 72070
3 View 72072
4 View 72074

THORACOLUMBAR SPINE
2-3 View 72080

LUMBAR SPINE
2-3 View 72100
4 View 72110

LUMBROSACRAL SPINE
Complete 72114

STERNUM
2 View 71120

TIBIA / FIBULA R L
2 View 73590

TMJ JOINTS R L
Unilateral Open & Closed 70328

WRIST(S) R L
2 View 73100
3+ View 73110

BONE DENSITY 77080

ULTRASOUND

ABDOMEN
COMPLETE 76700
LIMITED 76705
Aorta / AAA Screening 76706
Retroperitoneal Complete 76770
Retroperitoneal Limited 76775

PELVIC
Transabdominal Only 76856
Transvaginal 76830

SCROTUM
Scrotum & Contents 76870

SOFT TISSUE NECK
Thyroid / Parathyroid 76536

SOFT TISSUE / JOINT NON VASCULAR
Limited 76882

VASCULAR

ABDOMEN / RETROPERITONEAL / SCROTUM
COMPLETE 93975
LIMITED 93976

BILATERAL ARTERIES
Upper Extremity 93930
Lower Extremity 93925

UNILATERAL ARTERIES
Upper Extremity R L 93931
Lower Extremity R L 93926

AORTA / IVC / ILIAC
COMPLETE 93978
LIMITED 93979

BILATERAL VEINS
Upper Extremity 93970
Lower Extremity 93970

UNILATERAL VEINS
Upper Extremity R L 93971
Lower Extremity R L 93971

BILATERAL CAROTID
Dop-Extracranial Artery 93880