Ultrasound Referral Form Moscow Diagnostic Ultrasound
Insurance Billed Ultrasounds-Allied Imaging Assoc
PHONE 208-410-6044
Moscow Diagnostic Ultrasound Call for appointment set up
FAX 208-545-9528
Allied Imaging Assoc fax insurance information
EMAIL tinyhearts3dultrasound@protonmail.com
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Referring Provider Facility Name
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Referring Provider Point of Contact Name
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Referring Provider Fax Number
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Clinical History (Signs, Symptoms, Diagnosis, Reason for Exam; NO "Rule Out"
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ULTRASOUND TEST(S) ORDERED--PLEASE CHECK THE APPROPRIATE BOX(ES)
GENERAL ULTRASOUND EXAMS
Abdominal Complete- 76770
Abdominal Limited (RUQ/LUQ)- 76705
Renal with Bladder (Pre and Post Void)- 76770
Bladder Only- 76857
Aorta AAA Screening (Only)- 76706A
Appendix- 76705
OB/GYN ULTRASOUND EXAMS
OB 1st Trimester Less Than 14 weeks- 76801
OB Greater Than 14 weeks- 76805
OB 2nd Trimester 20 Week Anatomy- 76811
Nuchal Translucency (12-13.6 weeks)- 76813
OB Limited (AFI, Position, Placenta, Heart Beat) - 76815
OB Follow Up (Growth, re-evaluate Organs not seen previous)- 76816
OB Transvaginal Add On- 76817
OB BPP Biophysical Profile (without non-stress testing)- 76819
Pelvic Complete Transabdominal Only- 76856
Pelvic Transvaginal- 76830
Duplex Ovaries (Acute Pain Less than 3 days)- 93975
Pelvic Limited Transabdominal Only- 76857
Follicle Scan/Fertility Transvaginal- 76857
SMALL PARTS & SOFT TISSUE ULTRASOUND EXAMS
Thyroid- 76536
Soft Tissue Mass(NO BREAST)- 76882
Testicular- 76870
Testicular With Duplex (Acute Pain Less than 3 days)- 76870, 93975
Hernia (Inguinal or Umbilical)- 76857
EXTRACRANIAL ULTRASOUND EXAMS
Carotid Complete- 93880
VENOUS EXTREMITY ULTRASOUND EXAMS
Lower Extremity Venous Duplex - Bilateral- 93970
Lower Extremity Venous Duplex - Unilateral- 93971
Right
Left
Upper Extremity Venous Duplex - Bilateral- 93970
Upper Extremity Venous Duplex - Unilateral- 93971
Right
Left
ARTERIAL EXTREMITY ULTRASOUND EXAMS
Lower Extremity Arterial Duplex - Bilateral- 93925
Lower Extremity Arterial Duplex - Unilateral-93926
Right
Left
Upper Extremity Arterial Duplex - Bilateral-93930
Upper Extremity Arterial Duplex - Unilateral-93931
Right
Left
ABDOMINAL VASCULAR ULTRASOUND EXAMS
Renal Artery Duplex - 93975
Liver Doppler with Abdomen Complete- 93975
Abdominal Aorta, Iliac Arteries Complete 93978
ECHOCARDIOGRAM ULTRASOUND EXAMS (COMING SOON)
Pediatric Echocardiogram Complete (Ages Newborn-17 years old) - 93306, 93320, 93321
Adult Echocardiogram (Ages 18 and up) - 93306, 93320, 93321
Follow up or Limited - 93308
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