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ballweg
GAIL P. BALLWE(7 M.ll., Y.A. 7100 West 20`t' Ave Suite G 176 . I-Hialeah, FL 33016 (305)823-6777 Fax: (954)433-7402 NEUROLOGICAL PROCEDURF,S REQUEST PATIENT NAME DIAGNOSIS DATE OF APPOINTMENT i CT SCANS CPT CO DES BRAIN W/OUT 70450 BRAIN WITH & W/OUT ~ 70470 _ CERVICAL W/OUT 72125 _ CERVICAL WITH & W/OUT 72127 _ THORACIC W/OUT 72128 THORACIC WITH & W/OUT ~ 72130 _ LLM3AR W/OUT 72131 _ LUMBAR WITH & W/OUT 72133 ____ CT ANGIOGRAM 70496 MRI CPT CODES BRA1N W/OUT 70551 BRA1N WITH & W/OUT 70553 CERVICAL W/OUT 72141 CERVICAL WITH & W/OUT 72156 THORACIC W/OUT ~ 72146 _ THORACIC WITH & W/OUT 72157 LUMBAR W/OUT 72148 LUMBAR WITH & W/OUT 72158 TMJ W/OUT 70540 BRACHIAL PLEXUS WITH ~ 73219 _ BRACHIAL PLEXUS W/OUT -73218 _ SLEEP STUDY CPTS PSG/SLEEP APNEA 95810 _ CPAP 95811 OTHER: G 92585 95930 95819 OR 95816 95812 705.46 70544 70549 -70547 *PLEASE BE ADVLSED AUTHORIZATIONS AND REFERRALS TAKE 7-10 BUSINESS DAYS TO BE APPROVED.** ~r x:Lc~ r~ a *POR FAVOR NOTE QUE ALLWE .D.,P.A. DATE AUTORIZACIONES Y REFERIDOS DEMORAN D 7-10 DIAS DE TRABAJO PARA SER APROVADOS.` LOCATION: EDS CPT CODES (UPPERS) EMG~ UNITS 95861 _ MOTOR 6 UNITS 95903 _ SENSORY 6 iJNITS 95904 _ (LOWERS) EMG 2 UNITS 95861 _ MOTOR 6 L7NITS 95903 SENSORY 6 UNITS .95904 . _ H REFLEX 2 UNITS 95934 EVOKED POTENTIALS EAR ~VEP . EEG EEG AWAKE _ EEG SLEEP DEPRIVED MRA CPT CODES HEAD WITH & W/OUT ~_ HEAD W/OUT _ NECK WITH & W/OUT NECK W/OUT CAROTID ULTRASOUND GAIL P. BALLWEG M.D., P.A. 7100 West 20~' Ave Suite G 176 Hialeah, FL 33016 (305)823-6777 Fax: (954)433-7402 JROLOGIC~ PATIENT NAME DIAGNOSIS URES REQUEST ~. _ ~ ` - DATE: ~ DATE OF APPOINTMENT CT SCANS CPT CODES BRA1N W/OUT 70450 _ BRAIN WITH & W/OUT 70470 _ CERVICAL W/OUT 72125 _ CERVICAL WITH & W/OUT 72127 _ THORACIC W/OUT 72128 _ THORACIC WITH & W/OUT 72130 _ LUMBAR W/OUT 72131 _ LUMB AR WITH & W/OUT 7213 3 _ _ CT ANGIOGRAM 70496 MRI CPT CODES BRAIN W/OUT 70551 BRAIN WITH & W/OUT 70553 _ CERVICAL WIOUT 72141 CERVICAL WITH & W/OUT 72156 _ THORACIC W/OUT 72146 _ THORACIC WITH & W/OUT 72157 _ _ LUMBAR W/OUT 72148 _ LUMBAR WITH & W/OUT 72158 _ TMJ W/OUT 70540 BRACHIAL PLEXUS WITH 73219 _ _ BRACHIAL PLEXUS W/OUT 73218 SLEEP STUDY CPTS PSG/SLEEP APNEA 95810 CPAP 95811 OTHER: 95861 95903 95904 95861 95903 95904. 95934 92585 95930 95819 OR 95816 95812 70546 70544 70549 70547 *PLEASE BE ADVISED AUTHORIZATIONS AND REFERRALS TAKE 7-10 BUSINESS DAYS TO BE APPROVED.* BALLWEG;fi~1.D.,P.A. LOCATION: EDS CPT CODES (UPPERS) EMG~ UNITS MOTOR 6 UNITS SENSORY 6 UNITS (LOWERS) EMG 2 UNITS MOTOR 6 UNITS _ SENSORY 6 UNITS H REFLEX 2 UNITS EVOKED POTENTIALS BAER VEP EEG EEG AWAKE EEG SLEEP DEPRIVED MRA CPT CODES HEAD WITH & W/OUT HEAD W/OUT NECK WITH & W/OUT NECK W/OUT CAROTID ULTRASOUND DATE *POR FAVOR NOTE QUE AUTORIZACIONES Y REFERIDOS DEMORAN D 7-10 DIAS DE TRABAJO PARR SER APROVADOS.