Please circle appropriate diagnostic codes cpt



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Please circle appropriate diagnostic codes

CPT: (American Medical Codes)

70486

Computed Tomography, Maxillofacial area without contrast

70310

Radiologic examination, complete full mouth

76376

3D rendering with interpretation

70320

Radiologic exam, partial, less than full mouth

76380

Computed Tomography, localized study

70328

Radiologic exam, tempomandibular joint, open and closed


ICD-10 Codes: (International Medical Codes)

J32.9

Unspecified chronic sinusitis

K08.3

Retained dental root

K00.1

Supernumerary teeth

K08.401

Partial edentulism, class I

K00.6

Disturbances in tooth eruption (impaction)

K08.402

Partial edentulism, class II

K03.0

Excessive attrition

K08.403

Partial edentulism, class III

K04.8

Radicular cyst (apical, periapical)

K08.404

Partial edentulism, class IV

K05.21

Aggressive periodontitis, localized

K08.409

Partial edentulism, unspecified

K05.22

Aggressive periodontitis, generalized

K08.419

Loss of teeth due to trauma

K08.101

Complete edentulism, class I

K08.429

Loss of teeth due to periodontal disease

K08.102

Complete edentulism, class II

K08.439

Loss of teeth due to caries

K08.103

Complete edentulism, class III

K08.499

Other loss of teeth

K08.104

Complete edentulism, class IV

K09.0

Developmental odontogenic cysts

K08.20

Atrophy edentulous alveolar

M26.62

Arthralgia of temporomandibular join

K08.21

Minimal atrophy of mandible

M26.69

TMJ sounds on openings and/or caries

K08.22

Moderate atrophy of mandible

M27.2

Inflammatory conditions

K08.23

Severe atrophy of mandible

R20.8

Other disturbance of skin sensation

K08.24

Minimal atrophy of maxilla

S02.5XXA

Tooth broken/fractured due to trauma, closed

K08.25

Moderate atrophy of maxilla

S02.5XXP

Tooth broken/fractured due to trauma, open

K08.26

Severe atrophy of maxilla








ADA Codes: (Dental Codes)

D0360

CB CT-craniofacial data

D0368

CB CT capture and interpretation for TMJ series including two or more exposures

D0362

CB 2D multi image reconstruction

D0380

CB CT image capture with limited field of view – less than one whole jaw

D0363

CB 3D multi image reconstruction

D0381

CB CT image capture with field of view of one full dental arch – mandible

D0364

CB CT capture and interpretation with limited field view – less than whole jaw

D0382

CB CT image capture with field of view of one full dental arch – maxilla

D0365

CB CT capture and interpretation with limited field of one full dental arch – mandible

D0383

CB CT image capture with field of view of both jaws, with or without cranium

D0366

CB CT capture and interpretation with field of view of one full dental arch – maxilla

D0384

CB CT image capture for TMJ series including two or more exposures

D0367

CB CT capture and interpretation with field of view of both jaws – with or without cranium

D0391

Interpretation of diagnostic image by a practitioner not associated with capture of the image, including report




Please circle the Region of Interest (ROI)

  • Orthodontics

  • Sinus Exam

  • Endodontics



  • Airway Assessment

  • Dental Impaction

  • Oral Pathology



  • Implants

  • TMJ Exam



  • Maxilla

  • Mandible

  • Both Arches



Appointment Details


Preferred Reproduction Format

  • CD

  • Glossy Prints

  • Via Internet

  • Radiological Report

  • All of the above

**Please circle appropriate diagnostic codes on back**

Implant brand: _____________________________

Viewing Software: ______________________

Special Instructions:

_____________________________________________________________________________________________________________________________________________________________________________________________








Indicate teeth or
area of interest:

1

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7

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32

31

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29

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17



Scheduling Information

Date of Appt: _____________ Exact Location: _________________________________________________________

Time: ___________________ _________________________________________________________

Referring Doctor Information

REFERRAL FORM

Name: _________________________________________ Acct Number: ____________________________________

Address: _______________________________________ E-mail: __________________________________________

Phone: ________________________________________ Fax: ____________________________________________







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