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Referring Physician Requisition

Click here to download a Open MRI referral information in PDF format.  Sheet will need to be printed out and signed by patient and physician before faxing.

CPT CODES
70336 MRI – TMJ Unilateral/Bilateral
70540 MRI – Orbit/Face/Neck
70542 MRI – Orbit/Face/Neck w/contrast
70543 MRI – Orbit/Face/Neck w & w/o contrast
70551 MRI – Brain
70552 MRI – Brain w/contrast
70553 MRI – Brain w & w/o contrast
71550 MRI – Chest
72141 MRI – Cervical Spine
72142 MRI – Cervical Spine w/contrast
72146 MRI – Thoracic Spine
72147 MRI – Thoracic Spine w/contrast
72148 MRI – Lumbar Spine
72149 MRI – Lumbar Spine w/contrast
72156 MRI – Cervical Spine w & w/o contrast
72157 MRI – Thoracic Spine w & w/o contrast
73722 Arthrogram (Ankle, Hip, Knee)
73222 Arthrogram (Elbow, Shoulder, Wrist)
74185 MRA Abdomen w & w/o contrast renal
70544 MRA Head
70545 MRA Head w/contrast
70546 MRA Head w & w/o contrast
72158 MRI – Lumbar Spine w & w/o contrast
72195 MRI – Pelvis
72196 MRI – Pelvis w/contrast
72197 MRI – Pelvis w/ & w/o contrast
73218 MRI – Upper Extremity (not joint)
73219 MRI – Upper Extremity (not joint) w/contrast
73220 MRI – Upper Extremity (not joint) w & w/o contrast
73221 MRI – Upper Extremity Joint
73222 MRI – Upper Extremity Joint w/contrast
73223 MRI – Upper Extremity Joint w & w/o contrast
73718 MRI – Lower Extremity (not joint)
73719 MRI – Lower Extremity (not joint) w/contrast
73720 MRI – Lower Extremity (not joint) w & w/o contrast
73721 MRI – Lower Extremity Joint
73722 MRI – Lower Extremity Joint w/contrast
73723 MRI – Lower Extremity Joint w & w/o contrast
70547 MRA Carotid Dry
70548 MRA Neck w/contrast
70549 MRA Neck w & w/o contrast
71555 MRA Chest w & w/o contrast
72159 MRA Spinal Canal & Contents w or w/o contrast
72198 MRA Pelvis w or w/o contrast

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