EFTA00304571.pdf

HARRY FISCH, MD (PIN #D91790) OTISID/EiTi ID Number:IIPIMInal 944 Park Avenue (212) 879-0800 New York, NY 10028 n Patient Name: 3a-c-c-R Ey5jew Date of Service: Date of Birth: Unit Number OFFICE VISIT FEE ULTRASONOGRAPHY New Patient Level II FEE 99202 Bladder Scan New Patient Level III 51798 99203 Cystoscopy 52000 Transrectal Prostate 1-•"...' 76872 !SOO Established Patient Visit Level II 99212 Testicular (Scrotal) 76870 Established Patient Visit Level III 99213 Testicular w/Doppler 93975 Ultrasound Bladder se.---7 76856 /MO SURGICAL PROCEDURES FEE DIAGNOSIS Biopsy of Testis (Needle) 54500 Acute Prostatitis MS Biopsy of Testis (IncIslonal) 54505 Azoospermia Epididymovastostomy (Unilateral) CIF 54900 BPH Epididymovastostomy {Bilateral} ills 54901 Chronic Prostatitis Hydrocelectomy (Unilateral) Gdii a 55040 Condyloma of Penis Hydrocelectomy (Bilateral) 01#118 55041 Hematuria TUR Ejaculatory Ducts IS 52402 Hydrocele Varicocelectomy (Unilateral) ila 55530 Infertility, Male Varicocelectomy (Bilateral) MS 55530(50) Orchitis/Epididymitis Vasovasostomy (Unilateral) a 55400 Peyronie's Disease Vasovasostomy (Bilateral) it 55400(50} Pituitary Dysfunction Vasectomy 4MIIII 55250 Prostate Cancer a Renal Stone IS. DIAGNOSTIC TEST TO BE SCHEDULED Testicular Failure aStal 1-"*".. al Transrectal Prostate Sonogram Testicular Pain IS Testicular Sonogram LITI Testicular Sonogram w/Doppler Varicocele IIMIIP Penile Duplex Doppler Voluntary Sterilization 40.11* Bladder Ultrasound Cystoscopy CHARGE PYNIT CASH CHECK RECEIVED a`-too a LIoo I certify that I have rendered the above service: EFTA00304571