CT   CT Scans Brain 70450 CT Head or Brain w/o 70460 CT Head or Brain w 70470 CT Head or Brain w & w/o Orbits 70480 CT Orbits Sella Ears w/o 70481 CT Orbits Sella Ears w 70482 CT Orbits Sella Ears w & w/o Maxillofacial Sinus 70486 CT Maxillofacial w/o 70487 CT Maxillofacial w 70488 CT Maxillofacial w & w/o Neck Soft Tissue 70490 CT Soft Tissue Neck w/o 70491 CT Soft Tissue Neck w 70492 CT Soft Tissue Neck w & w/o Chest 71250 CT Chest w/o 71260 CT Chest w 71270 CT Chest w & w/o Abdomen 74150 CT Abdomen w/o 74160 CT Abdomen w 74170 CT Abdomen w & w/o Pelvic 72192 CT Pelvis w/o 72193 CT Pelvis w 72194 CT Pelvis w & w/o   (CT Urography Protocol )   Cervical Spine 72125 CT Cervical Spine w/o 72126 CT Cervical Spine w 72127 CT Cervical Spine w & w/o CT Thoracic Spine 72128 CT Thoracic Spine w/o 72129 CT Thoracic Spine w 72130 CT Thoracic Spine w & w/o CT Lumbar Spine 72131 CT Lumbar Spine w/o 72132 CT Lumbar Spine w 72133 CT Lumbar Spine w & w/o CT Upper Extremity 73200 CT Upper Extremity w/o 73201 CT Upper Extremity w 73202 CT Upper Extremity w & w/o CT Lower Extemity 73700 CT Lower Extremity w/o 73701 CT Lower Extremity w 73702 CTLower Extremity w & w/o   Without IV Contrast With IV Contrast With 3D Reformatted Images     CT Angiography 71275 CTA Chest (PE, Aorta, etc.) Low Dose Radiation Protocol 75574 With Coronary and Wall Motion Analysis 75574 Without Coronary 75572 Wall Motion Analysis 70498 CTA Neck (TIA, Carotids, Vertebrobasilar) 70496 CTA Head (TIA, Cerebrovascular) 74175 CTA Abdomen (Aneurysms, Stenosis, Renal, Mesentery) 72191 CTA Pelvis (Aneurysms, Stenosis, DVT, Iliac) 73206 CTA Upper Extremity 73706 CTA Lower Extremity (Stenosis, DVT, Femoral) 75635 CTA Aorta & Lower Extremity (AAA, Stenosis, Aortofemoral Runoff) 73706 CT Venogram Lower Extremity (DVT, Edema) G0288 Reconstructive CTA Aorta Pre-Thoracic Surgery 75571 Coronary Calcium Score (Diagnostic)   Screening CT (Cash procedure - not covered benefit) Whole Body CT Coronary Calcium (No Lung Over-Read) Chest (Full Lung Scan) Coronary Calcium & Chest Virtual Colonography CT Coronary Angiography (for Screening)   Ultrasound Specify   Patient Name Phone D.O.B. Diagnosis / Symptoms Desired Appointment Time & Date To optimize coronary images, IV Beta Blockers may be used to obtain heart rates of 55-65. Is there any reason that we should avoid using Beta Blockers on your patient? Yes No Allergic To Iodine DM CKD Known Arrhythmia Pacemaker Asthma Known Allergies     For Contrast Studies:     Creatinine BUN Date Referring Physician Full Name (in lieu of signature) Copies Sent to Date   Phone Fax Email

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Westside Medical Associates of Los Angeles

Copyright ©2013 Westside Medical Imaging
64-Slice CT Scan, Body, Heart, and Vascular Imaging in Southern California
99 N La Cienega Blvd. • Suite 103 • Beverly Hills, CA • 310.623.1150