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1542.11.19 SJRA Form_Layout 1 12/26/19 11:45 AM Page 1

Patient Name: ______DOB: ______Date: ______Ordering Physician Name: ______Ordering MD Signature: ______Phone: ______Fax: ______Physician Address: ______Reason for Exam: ______Dx Code(s): ______PreCert#/Authorization # ______Notes: Radiology procedure not listed, special protocol request specific area of interest: ______BREAST IMAGING GENERAL X-RAY DOPPLER Code Procedure Code Procedure Code Procedure K 77067 Screening Mammogram K 73502 Hip Unilateral specify with or without K 93930 Arterial Duplex Upper Extremity Bllateral 77063 Screening digital pelvis 2 or 3 views (Specify RT or LT) K 93931 Arterial Duplex Upper Extremity Unilateral 76641 Breast if necessary K 73060 Humerus (Specify RT or LT) (Specify RT or LT) K 77066 Diagnostic Mammogram - Bilateral K 73592 Infant Lower Extremity up to 12 months K 93880 Carotid G0279 Diagnostic digital breast tomosynthesis (Specify RT or LT) G K 93925 Graft Imaging Duplex Lwr Extremity 76642 Ultrasound Breast if necessary K 73092 Infant Upper Extremity up to 12 month Bllateral K 77065 Diagnostic Mammogram - Unilateral (Specify RT or LT) K 93926 Graft Imaging Duplex Lwr Extremity G0279 Diagnostic digital breast tomosynthesis K 73564 Knee Routine (Specify RT or LT) - 4 views Unilateral (Specify RT or LT) 76642 Ultrasound Breast if necessary K 73560 Knee 1 or 2 views (Specify RT or LT) K 76882 Groin K 76641 Ultrasound Asymptomatic Breast - K 72100 Lumbar Spine 2 or 3 views K 93926 Groin with Doppler for pseudoaneurysm Complete (Specify RT LT or Bilateral) K 72110 Lumbar Spine Routine 4 or more K 76856 Pelvic w/ Doppler K 76642 Ultrasound Breast LIMITED - mammo K 72114 Lumbar Spine w/Fexion and Extension 76830 Pelvic with TA & TV & Doppler finding, Follow/up or Symptomatic Bending views, 6 views 93976 K 10005 US Guidance Breast FNA Bx K 72120 Lumbar Spine Bending Only 2 or 3 views K 93975 Mesentery Doppler K (Specify RT or LT) 70110 Mandibie K 76775 Renal with Doppler K K 10005 US Guidance Breast FNA Bx - Bilateral 70160 Nasal Bones 93975 K 10006 70360 Neck K 76830 Transvaginal Doppler K K 77046 MRI Breast Unilateral (Specify RT or LT) w/o 70200 Orbits 93975 K K 77046 MRI Breast Unilateral 70220 Paranasal Sinuses K 76830 Transvaginal W/Doppler for ovarian Torsion K 72170 Pelvis (Implant Evaluation) (Specify RT or LT) 93976 K 71111 Ribs Bilateral & PA Chest K 77047 MRI Breast BL w/o K 93985 Venous Upper Vein Mapping K 71101 Ribs Unilateral w/PA Chest (Specify RT or LT) K 77047 MRI Breast BL (Implant Evaluation) Pre AV Fistula Bilateral K 72202 Sacroiliac Joints K 77048 MRI Breast Unilateral w & w/o K 93986 Venous Upper Vein Mapping K 72220 Sacrum and Coccyx Pre AV Fistula Unilatera (Specify RT or LT) K K 77073 Scanogram - Bone Length Venous Doppler Upper (arms) 77049 MRI Breast BL w & w/o K 73010 Scapula (Specify RT or LT) K 19000 Breast Cyst Aspiration K 93970 Bilateral K 72081 Scoliosis Study view K 93971 Unilateral (Specify RT or LT) (Specify RT LT or Bilateral) K 73030 Shoulder (Specify RT or LT) K 19081 Stereotactic Breast Venous DVT Study Lower (legs) Extremity K 70260 Skull K 93970 Bilateral (Specify RT LT or Bilateral) K 77075 K 93971 Unilateral (Specify RT or LT) K 19281 Needle Localization with Mammographic K 71130 Sternoclavicular Joints Venous lnsufficiency/Reflux Exam Lower (legs) Guidance (Specify RT LT or Bilateral) K 71120 Sternum Extremity K 19083 Core Biopsy with Ultrasound Guidance K 72070 Thoracic AP & LAT K 93970 Bilateral (Specify RT LT or Bilateral) K 73590 Tibia & Fibula (Specify RT or LT) K 93971 Unilateral (Specify RT or LT) K 19285 Needle Localization with Ultrasound K 73660 Toe min 2 views (Specify RT or LT) Venous Post EVLT Lower (legs) Extremity Guidance (Specify RT LT or Bilateral) K 73110 Wrist (Specify RT or LT) K 93970 Bilateral K 19085 MRI Guided Core Biopsy K 73523 Hips Bilateral 5 or more views K 93971 Unilateral (Specify RT or LT) (Specify RT LT or Bilateral) w or w/o Pelvis K 19287 Needle Localization with MRI Guidance (Specify RT LT or Bilateral) ULTRASOUND Code Procedure Code Procedure K BONE DENSITY K 74221 Barium Swallow include scout chest 76775 Abdomen Aorta K Code Procedure Double Contrast 76700 Abdomen Complete K K 77080 DExASCAN K 74246 Upper GI including scout Abdominal 76700 US Abdomen Complete w/ K 77085 DExA Vertebral Fracture assesment Double Contrast 76981 K K 74246 Upper GI including scout Abdominal 76705 US Abdomen Limited w/Liver 74248 Double Contrast with Small Bowel 76981 Elastography GENERAL X-RAY K K 74250 Small Bowel include scout Abdominal 76705 Abdomen Limited Code Procedure K Single Contrast 76705 Abdomen Wall K 74022 Abdomen Obstruction Series including K K 74270 Barium Enema scout Abdominal 76882 Axilla Chest 1 view K 76857 Bladder (Pre & Post Voiding) K Single Contrast 74018 Abdomen 1 view K 76604 Chest Wall K K 74280 Barium Enema scout Abdominal 73050 Acromioclavicular Joints B/L K 76881 Extremity Non-Vascular Complete K Double Contrast 73610 Ankle (Specify RT or LT) K 76801 Fetal Uterus < 14 Weeks (TV if needed) K 77072 Bone Age Study DOPPLER 76817 K 72040 Cervical Spine 2 or 3 views K 76805 Fetal Uterus > 14 weeks with TV if needed K 72050 Cervical Spine Routine - 5 views Code Procedure 76817 K K 72052 Cervical Spine w/Flexion & Extension 76775 Abdomen Aorta w/Doppler K 76815 Fetal Limited/Follow up K 71046 Chest 2 views 93978 K 76885 Infant Hips K K 73000 Clavicle (Specify RT or LT) 76700 Abdomen Complete w/Doppler K 76705 Hernia (any) K 73080 Elbow (Specify RT or LT) 93975 K 76882 Limited-Extremity Specific K K 70150 Facial Bones 76705 Abdomen Limited (liver) w/Doppler BODY PART:______K 73552 Femur min. 2 views (Specify RT or LT) 93975 K 76536 Neck, or Parathyroid K K 73620 Foot 2 views (Specify RT or LT) 93922 Arterial Doppler Bilateral ABI ONLY K 76770 Renal Aorta Nodes K K 73630 Foot Routine (Specify RT or LT) 93923 Arterial Upper Extremity Multiple Levels K 76770 Renal Bladder K 73090 Forearm (Specify RT or LT) Bilateral K 76775 Renal Limited w/o bladder K K 73130 Hand Routine (Specify RT or LT) - 4 views 93923 Arterial Lower Extremity Multiple Levels K 76776 Renal Transplant K 73650 Heel (calcaneus) min 2 views ABI Bilateral K 76856 Pelvic - Non - OB (TV if needed) (Specify RT or LT) K 93925 Arterial Duplex Lower Extremity Bilateral K 76830 K K 73522 Hip Bilateral specify with or without 93926 Arterial Duplex Lower Extremity K 76830 Transvaginal - Non-OB pelvis 3 or 4 views Unilateral (Specify RT or LT)

01/2020 1542.11.19 SJRA Imaging Form_Layout 1 12/26/19 11:45 AM Page 2

Patient Name: ______DOB: ______Date: ______Ordering Physician Name: ______Ordering MD Signature: ______Phone: ______Fax: ______Physician Address: ______Reason for Exam: ______Dx Code(s): ______PreCert#/Authorization # ______Notes: Radiology procedure not listed, special protocol request specific area of interest: ______SOFT TISSUE MASS, CT MRI ULTRASOUND EVALUATION Code Procedure Code Procedure Code Procedure CT MRI ExTREMITY- UPPER JOINT K 76882 Axilla K 70450 w/o contrast BODY PART:______(Specify RT or LT) K 76705 Abdominal Wall K 70460 with contrast K 73221 w/o contrast K 76857 Buttocks (Specify RT, LT or Bilateral) K 70470 with contrast & w/o contrast K 73223 with contrast & w/o contrast K 93976 Doppler if needed CT CHEST MRI ExTREMITY-LOWER NON-JOINT K 76604-52 Chest Wall K 71250 w/o contrast BODY PART:______(Specify RT or LT) K 76604-52 Upper Back K 71260 with contrast K 73718 w/o contrast K K 76882 Groin K 74261 CT Colonography Diagnostic 73720 with contrast & w/o contrast K 76705 Lower Back K 74263 CT Colonography Screening MRI ExTREMITY- LOWER JOINT K K BODY PART:______(Specify RT or LT) 76536 Neck 74177 CT Enterography with contrast K K 74178 CT Enterography w & w/o contrast 73721 w/o contrast K 73723 with contrast & w/o contrast CT ExTREMITY - LOWER BODY MRI Pelvis w/o contrast Code Procedure PART:______(Specify RT or LT) K K 72195 w/o contrast K 78300 Bone Scan - Limited Area 73700 w/o contrast K 72197 with contrast & w/o contrast K K 78305 Bone Scan Multiple Areas 73701 with contrast MRI () K 78315 Bone Scan - Three Phase Study K 73702 with contrast & w/o contrast K 72197 w&w/o contrast K 78306 Bone Scan – Whole Body CT ExTREMITY - UPPER BODY K 76377 with contrast+ 3D Recon K 78803 Bone SPECT PART:______(Specify RT or LT) MRI Cervical Spine K 78803 Bone S PECT Scan + Whole Body K 73200 w/o contrast K 72141 w/o contrast 78306 K 73201 with contrast K 72156 with contrast & w/o contrast K 78803 Brain SPECT S can K 73202 with contrast & w/o contrast MRI Thoracic Spine K 78802 Gallium Infection 24hr Scan (Whole Body) CT Neck, Soft Tissue K 72146 w/o contrast K 78801 Gallium Infection 48hr Scan (Limited) K 70490 w/o contrast K 72157 with contrast & w/o contrast K 78801 Gallium Infection 48hr Scan (Multi-Area) K 70491 with contrast MRI Lumbar Spine K 78804 Gallium Infection 48hr Scan (Whole Body) K 70492 with & w/o contrast K 72148 w/o contrast K K 78803 Kidney SPECT K 70480 CT Orbit/Temporal Bones w/o contrast 72158 with contrast & w/o contrast K K 70486 CT Sinus/Maxillofacial MRI Neck 78803 Liver SPECT & Statics K K 78831 Local. of Abcess SPECT (Whole Body) K 70486 CT Sinus (Landmark or Stryker) 70540 w/o contrast K 70543 with & without contrast K 78258 Esophageal Transit Motility Scan CT CERVICAL SPINE K 78264 Gastric Emptying Study K 72125 w/o contrast K 78226 Hepatobiliary Imaging w/o CCK K 72126 with contrast MRA K 78227 Hepatobiliary w CCK CT LUMBAR SPINE Code Procedure K 78215 Liver & Spleen Imaging -Static only K 72131 w/o contrast K 74185 MRA Abdomen (Aorta-Renal) K 78290 Meckels K 72132 with contrast MRA Abdomen to Lower Legs (Runoff) K 78070 Parathyroid Planar Imaging CT THORACIC SPINE to inc bilateral legs K 78072 Parathyroid SPECT/CT K 72128 w/o contrast K 74185 K 73725 K 73725 K 78707 Renal Flow & Function K 72129 with contrast MRA Brain K CT Knee (Specify RT or LT) K 70544 w/o contrast 78709 Renal Scan Captopril K K 78708 Renal Scan w/ Lasix K 73701 K 27369 K 77002 70546 with contrast & w/o contrast K MRA Carotids 78014 Thyroid Uptake & Scan K K 70547 w/o contrast 79005 Thyroid I131 Therapy MRI K 70549 with contrast & w/o contrast Code Procedure MRA Iliac Artery CTA MRI Abdomen K 72198 K 73725 Code Procedure K 74181 w/o contrast K 71555 MRA Thoracic Aorta (Chest) K 74175 CTA Abdomen K 74183 with contrast & w/o contrast K 73225 MRA Upper Extremity with or w/o contras t K 74174 CTA Abd. & Pelvis MRI Arthogram RT____ LT____ K 75635 CTA AORTA & Run Off Shoulder K 23350 73222 CARDIAC IMAGING Elbow K 24220 73222 K 70496 CTA Brain Code Procedure - ECHO K 70498 CTA Carotid/Neck Wrist K 25246 73222 K K 93306 Transthoracic Echocardiogram K 71275 CTA Chest Non-Cardiac Hip 27093 73722 2D w/Spectral & Color Flow Doppler K K 71275 CTA Chest Pulmonary Embolism Knee 27369 73722 K 93351 Transthoracic Echocardiogram 2D w/Stress K K 73706 CTA Lwr. Extremity Ankle 27648 73722 Code Procedure - MRI K 73206 CTA Upr. Extremity MRI Brain K 75557 Cardiac MRI without contrast K 70551 w/o contrast K 75561 Cardiac MRI with contrast & w/o contras t K 70553 with contrast & w/o contrast CT Code Procedure - CAT SCAN MRI Breast with or w/o contrast K 75571 CT Heart Calcium Scoring Code Procedure K 77048 MRI Breast w-wo Contrast, K 75574 CTA Heart Coronary Arteries CT ABDOMEN Unilateral (Specify RT or LT) Code Procedure - NUCLEAR CARDIOLOGY K 74150 w/o contrast K 77048 MRI Breast w-wo Contrast, K 93015 Exercise Stress Treadmill (non-nuclear) K 74160 with contrast Bilateral K 78472 Muga Scan K 74170 with contrast & w/o contrast MRI Chest - Brachial Plexus K 78452 Myocardial Perfusion SPECT Persantine CT PELVIS K 71550 w/o contrast Rest/Stress Multiple Study K 72192 w/o contrast K 71552 with contrast & w/o contrast K 78472 Myocardial Perfusion SPECT Rest/Stress K 72193 with contrast MR Cholangiopancreatography (mrcp) Multiple Study K 72194 with contrast & w/o contrast K 74181 K 74183 CT ABDOMEN & PELVIS MRI Enterography (Small Bowel) PET IMAGING K 74176 w/o contrast K 74183 K 72197 Code Procedure K 74177 with contrast MRI ExTREMITY-UPPER NON-JOINT K 78815 PET/CT Tumor Imaging K 74178 with contrast & w/o contrast BODY PART:______(Specify RT or LT) (Base of Skull to Mid-Thigh) K 74178 CT Urogram K 73218 w/o contrast K 78816 PET/CT Tumor Imaging K 74176 CT Stone Study K 73220 with contrast & w/o contrast Whole Body Scan

01/2020