Phone :
404-236-7700
Toll Free :
866-360-6622
Fax :
404-236-7701
Email :
info@360imaging.com
Address :
360imaging, Inc.
Corporate Office and Digital Lab
One Concourse Parkway
Suite 645
Atlanta, GA 30328
Dental CT Scan (CPT 70486)
Patient Name:
Patient Phone:
Doctor Name:
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Case Type (Select One)
Implant
Impaction
Supernumerary
Pathology
Sinus
TMJ Study
Ortho
Other
Image Modeling Software (Select One)
Nobel
Keystone
Implant Logic
iDent
SimPlant
Dolphin
Facilitate
Other
Tx vision
TM
Implant Type
Sites Per Arch
Notes
Region of Interest (Select One)
Dual Arch Scan
Single Arch Scan
Quadrant Scan
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
Maxilla
Mandible
32
31
30
29
28
27
26
25
24
23
22
21
20
19
18
17