CARDIOVASCULAR RESEARCH INSTITUTE                Unit #:
Adult Pulmonary Function Laboratory
Visit #:                                Name:
                                                                                           Birthdate:

OUT_MOFF_PFT

                                                                                           Labdate:
                                                                                           Address:
                                                                                           Apt #:                                                                                                                             City, State, Zip:
                                                                                           Phone #:
 
Diagnosis: Dyspnea                              ICD9 Codes: 786.09
 
PFLab Attending: Warren M. Gold, MD               Technician: CM
Requesting Attending: R. A. Dudley, MD

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Procedures Performed                                                              pro       tech      total
                                                                     Pro         CPT         fee        fee       fee
Description                                                   #        Code(s)         ($)        ($)       ($)
 
Bicycle VO2 Max – Pre & Post                 925        94621             0         200     200
Totals                                                                                              0         200     200
 
Total pro fees charged   0
 
 
Visit #:
Mediphys = $ 0.00
Facility Fee = $ 200.00
Total Payment = $ 200.00