Maxilla Mandible Both Arches

Date:______* Please circle appropriate diagnostic code: area of interest: Indicate teethor dental billing references. If you have any questionsItis our orcommitm need additional information 525.22 527.9 526.9 525.25 525.20 525.12 525.11 525.10 524.63 733.02** 733.01** 733.00** 524.62* 526.4* 524.10* 473.9* 76376 70486* ______Instructions:______Special    Time:______Date of Appt:______Phone:______E Address:______Fax:______Name (Print):______Signature:______CPT CODE Referring doctor Information Information doctor Referring scheduling Information Information scheduling CODE Both Arches Maxilla Mandible

Serving New York, New Jersey, Connecticut, Pennsylvania, Maryland, Virginia and Washington D.C. D.C. Washington and Virginia Maryland, Pennsylvania, Connecticut, Jersey, New York, New Serving

 

TMJ Exam Implants

entto provide our valued customers with the tools and resources to achieve the highest level of success. We have prepared th Moderate atrophy of mandible Unspecified disease of the salivary glans Unspecified atrophy of edentulous alveolar ridge Loss ofteeth due toperiodontal disease Loss ofteeth due totrauma Unspecified acquired absence of teeth Osteoporosis Unsp Endodontic Overfill Inflammatory Conditions (Jaw) Unspecified disease of jaw Moderate atrophy of the maxilla Articular disc Idiopathic Osteoporosis Senile Osteoporosis Unspec anomaly (jaw to crani Unspec sinistis (chronic) 3D Rendering W/interp/rptg of CAT CAT

- Maxillo facial are: W/O Contrast Tel: (800) 881 (800) Tel:

disorder of temporomandibular joint

 

Oral Pathology Dental Impaction

Description DESCRIPTION

Payment is due when services are r

al base)

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Must be billed w/base imaging

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4432 • Fax: (516) 977 (516) Fax: • 4432

Phone:______Cell:______Address:______Name:______D.O.B:______Please circle the Region of Interest (ROI)

Patient Information Information Patient

, please don’t hesitate to contact us at 800

Diagnosis codes Diagnosis cpt codes cpt  

Airway Assessment Endodontics Exact Location______(Please

719.48 526.2 524.60 525.12 521.11 733.03** 528.4 76380** 521.10 733.40** 733.09** OTHER 525.23 733.20 784.0 525.26 52 CPT CODE

4.69 CODE

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endered by check, cash or major credit card.

- Pain in joint, other specified sites Other cysts of jaw Unspecified TMJ disorder Excessive attrition, extending in to dentine Excessive attrition, Limited to enamel Disuse Osteoporosis Cysts of oral soft tissue CAT - 9899 • • 9899 Severe atrophy ofmandible Unspecified cyst of bone (localized) Headache Severe atrophy ofthe maxilla Other specified temporomandibular joint disorder Excessive attrition, U Aseptic necrosis of bone, site Unsp Other 881 City ______- 4432. - Limited or localized follow up study - Osteoporosis

- mail:______www.facialimagingmobile.com

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formedical and Address

State

 a radiological template? Is your patient coming with

 Yes                Sinus Exam Easy Guide Glossy Prints CD Other:______Free Simplant Viewer I Nobe Free NNT Viewer VIP Sim Dual Scan re nio Viewer InvivoFree All of the above Radiological Report Simplant Via Internet - Reproduction Dent 

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