HARRY FISCH, MD (PIN #D91790) 944 Park Avenue New York, NY 10028 Patient Name:lers-CAS'el EPSI-CIA/ Date of Birth: OFFICE VISIT New Patient Level II 99202 FEE New Patient Level III 4-*******-- 99203 Li 25 Established Patient Visit Level II 99212 Established Patient Visit Level III 99213 SURGICAL PROCEDURES Biopsy of Testis (Needle) 54500 FEE Biopsy of Testis (Incisional} 54505 Epididymovastostomy (Unilateral) 54900 Epididymovastostomy (Bilateral) 54901 Hydrocelectomy {Unilateral} 55040 Hydrocelectomy (Bilateral) 55041 TUR Ejaculatory Ducts 52402 Varicocelectomy (Unilateral) 55530 Varicocelectomy (Bilateral} 55530(50) Vasovasostomy {Unilateral} 55400 Vasovasostomy {Bilateral) 55400(50) Vasectomy 55250 DIAGNOSTIC TEST TO BE SCHEDULED 1111 Transrectal Prostate Sonogram Testicular Sonogram Testicular Sonogram w/Doppler Penile Duplex Doppler Bladder Ultrasound Cystoscopy CHARGE PYMT Sao CASH ID Number: (212) 879-0800 Date of Service: Unit Number: DI HY Bladder Scan 51798 FEE Cystoscopy 52000 Transrectal Prostate 76872 Testicular (Scrotal) 76870 Testicular w/Doppler 93975 Ultrasound Bladder 76856 DIAGNOSIS Acute Prostatitis 601.0 Azoospermia 606.0 BPH 600.00 Chronic Prostatitis 601.1 Condyloma of Penis 078.10 Hematuria 599.7 Hydrocele 603.9 Infertility, Male 606.9 Orchitis/Epicliclymitis 604.9 Peyronie's Disease 607.85 Pituitary Dysfunction 253.8 Prostate Cancer 185.0 Renal Stone 592.0 Testicular Failure >c , 257.2 Testicular Pain 608.9 till 599.0 Varicocele 456.4 Voluntary Sterilization V25.2 CHECK RECEIVED I certify that I have rendered the above service: EFTA00304570