DEAN T.

NORITAKE, MD
2750 E. Washington Blvd., Suite 120 Pasadena^A 91107 Last Name: First Name: Date:

New Patient Office Visit 99201 99202 99203 99204 99205 New Pt OV Level 1 New Pt OV Level 2 New Pt OV Level 3 New Pt OV Level 4 New Pt OV Level 5

73630 L R Foot, 3 Views 73090 L R Forearm. 2 Views 73120 L R Hand. 2 Views _73510 73520 Hip, 2 Views Hip Bilateral, 2 Views

719.0X 722.52 724.2 695.4 71 0.0 726.70 710.8 71 0.9 715.1X 715.0X 733.00 724.5 719.4X _729.5 _723.1 724.9 719.30

Joint Effusion. SITE Lumbar Disc. Degenerative Lumbago

- (0-9)

Lupus, Discoid, Erythematosus Lupus. Systemic Metatarsalgia Mix Connective Tissue Disease Unsp. Mix Connective Tissue Disease Osteoarth. SITE Osteoarth. SITE Osteoporosis Pain, Back Pain. Joint. Site Pain, Limb Pain, Neck Pain, Thoracic Spine Palindromic Rheumatism Paresthesia Peripheral Neuropathy Polyarteritis Nodosum Polvmvalaia Polymyositis Polyneuropatny Postmenopausal Psoriasis Radicu. Lower Radicu, Upper Raynauds Syndrome Rotator Cuff Tear Sarcodosis Sciatica Scleroderma Sjogren Syndrome Spondytosis, Cervical Spondytosis, Lumbosacral Spondytitis. Thoracic Spondyfolisthesis Spinal Stenosis. Site Temp Arteritis Tendonitis, Achilles Tendonitis. Bicipital Tendonitis. Calcifying Shoulder Tendonitis, Tibialis Tendonitis, Trigger Finger Tenosynovitis. De Quervain Tenosynovitis. Foot and Ankle Tenosynovitis, Hand/Wrisl Thoracic Disc, Degenerative Vasculitis, Cerebral Vasculitis, Cutaneous Site _'(0, 1,9) Vasculitis, Systemic Wegeners Granulomatosis WeighttossAbnormal ' (0. 1.2) '(0-9) * (0-8) (0. 4. 9)

73060 L R Humerus. 2 Views _73560 L R Knee. 2 Views _73564 L R Knee Bilateral, WB, 4nrw 72110 72170 Lumbar Spine, comp Pelvis AP only

Consultations 99243 99244 99245 99499 OP Consult Level 3 OP Consult Level 4 OP Consult Level 5 Study Visit

_71100 L R Ribs Unilat, 3 views _73030 L R Shoulder 2 Views 72202 SI Joints. 3 views _72070 Thoracic Spine, 2 vw _731 1 0 L R Wrist, 3 views Diagnosis _995.2 _726.0 _720.0 719.4X 713.1 714.30 _696.0 099.3 _714.0 711.0X 716.1X 716.9X 136.1 _726.61 _726.33 _726.39 _726.65 _726.19 726.5 Adverse Drug Reaction Adhesive Capsulitis Ankylosing spondytitis Arthralpia, SITE Arthritis, Enteropalhic Arthritis, Juvenile Arthritis, Psoriatic Arthritis, Reactive (Reiter) Arthritis, Rheumatoid Arthritis, Septic. SITE Arthritis. Traum, SITE Arthrooathv. SITE Bechets Bursitis, Anserine Bursitis, Olecrano Bursitis. Other Bursitis. Prepatellar Bursitis. Subacromial Bursitis. Trochanteric Carpal Tunnel Svndrome Chondrocalcinosis, SITE Compression Fracture Spine Costochondritis Dermatomvositis Diabetes Mellitus Drug Monitoring Drug Monitoring. Steroid Epicondylitis, Lateral Epicondylitis. Medial Fasciitis, Plantar Elevated Sed Rate Elevated Titer Fibromyalgia Fatigue and Malaise Gout Hypercholesterolemia Hyperthyroidism Hypothyroidism "(0-9) (0-9) * (0-9) '(0-9) ' (0-9)

Established Office Visit 9921 1 Est PI OV Level 1 99212 99213 99214 99215 99354 99355 Est Pt OV Level 2 Est R OV Level 3 Est R OV Level 4 Est R OV Level 5 Pron R OV Pron R OV

782.0 356.4 446.0 725 710.4 356.9 627.8 690.1 724.4 723.4 443.0 726.10 135.0 _724.3 710.1 710.2 72 1 .0 721 .3 712.2 756.12 724.0X 446.0 726.71 726.24 726.1 1 _726.72 726.03 727.04 727.06 727.05 722.51 _437.4 _446.2X 447.6 446.4 _ 783.21

Office Procedures 20550 20551 20552 20553 20600 20605 20610 J7323 J7321 J2920 86580 Infusion J1740 J0129 J9310 J1745 J3488 Boniva Units** Orencia Units # Rituximab # Remicade Units ft Reclast Units # Inj: Tendon Sheath Lig/Gang Cyst Inj: Tendon Origin/Insert lnj:1/Mutt.Trigger pt 1-2 lnj:1/Mult.Trigger pt 3+ Joint Aspiration, Small Joint Aspiration. Medium Joint Aspiration. Large Euflexxa Hyalgan/Supartz, 20mg Solumedrd. 40mg Tuberculin Skin Test

354.0 712.2X 733.12 733.6 710.3 250.00 V58.69 V58.65 726.32 726.31 _728.71 _J90.1 _ 795.79 _729.1 780.79 _274.00 272.00 __242.9 244.9

Nerve Conduction 95900 95903 95904 EA Nerve # Wave* Sensory*

X-Ray 736 1 0 L R Ankle, 3 Views 77080 71020 72052 72050 Bone Density DEXA Chest, 2 views Cervical Spine, 5 vw Cervical Spine, 7 vw

73080 L R Elbow, 3 Views 73550 L R Femur, 2 Views G8553 Other Diagnosis: Return Appointment: ( Days) ( Weeks) {

'5th digit-0-unspecified; 1-shoulden 2-upper arm; 3-forearm;4-hand; 5-pelvis/thigh; 6-lowleg; 7-ankle/foot; 8-other, 9 mult site PT BRINGS OWN

Referring Physician: Months) ( PRN) Doctors Signature:

Todays Fee:

DEAN T. NOR1TAKE, MD
2750 E.Washington Blvd., Suite 120 Pasadena CA 91107 Last Name: First Name: Date:

New Patient Office Visit 99201 99202 99203 99204 99205 New Pt OV Level 1 New PI OV Level 2 New Pt OV Level 3 New PtOV Level 4 New Pt OV Level 5

73630 L R Foot, 3 Views 73090 L R Forearm, 2 Views _73120 L R Hand. 2 Views 73510 _73520 Hip, 2 Views Hip Bilateral, 2 Views

71 9.0X 722.52 _724.2 695.4 _710.0 726.70 _ 710.8 _71 0.9 715. 1X 7I5.0X 733.00 _724.5 719.4X _729.5 _723.1 _724.9 719.30

Joint Effusion. SITE Lumbar Disc, Degenerative Lumbago

* (0-9)

Lupus, Discoid, Erythematosus Lupus, Systemic Metatarsalgia Mix Connective Tissue Disease Unsp. Mix Connective Tissue Disease Osteoarth, SITE Osteoarth. SITE Osteoporosis Pain, Back Pain. Joint. Site Pain, Umb Pain, Neck Pain, Thoracic Spine Palindromic Rheumatism Paresthesia Peripheral Neuropathy Potyarteritis Nodosum Porymyalgia Polymyositis Potyneuropathy Postmenopausal Psoriasis Radicu, Lower Radicu, Upper Raynauds Syndrome Rotator Cuff Tear Sarcodosis Sciatica Scleroderma Sjogren Syndrome Spondytosis, Cervical Spondytosis, Lumbosacral Spondylitis, Thoracic Spondylolisthesis Spinal Stenosis. Site Temp Arteritis Tendonitis, Achilles Tendonilis, Bicipital Tendonitis, Calcifying Shoulder Tendonitis, Tibialis Tendonitis, Trigger Finger Tenosynovitis. De Quervain Tenosynovitis, Foot and Ankle Tenosynovitis. Hand/Wrist Thoracic Disc, Degenerative Vasculitis, Cerebral Vasculitis, Cutaneous Site Vasculitis, Systemic Wegeners Granulomatosis Weight loss Abnormal "(0,1,9) * (0. 1 . 2) ' (0-9) ' (0-8) * (0. 4, 9)

73060 L R Humerus, 2 Views _73560 L R Knee. 2 Views _73564 L R Knee Bilateral, WB. 4-t-vw 72110 72170 Lumbar Spine, comp Pelvis AP only

Consultations 99243 99244 99245 99499 OP Consult Level 3 OP Consult Level 4 OP Consult Level 5 Study Visit

_71 100 L R Ribs Unilat, 3 views _73030 L R Shoulder 2 Views 72202 SI Joints. 3 views Thoracic Spine, 2 vw _72070

Established Office Visit 99211 99212 99213 99214 99215 99354 99355 EstPtOVLeveM Est Pt OV Level 2 Est Pt OV Level 3 Est Pt OV Level 4 Est Pt OV Level 5 PronPtOV Pron R OV

_73110LR Wrist, 3 views Diagnosis __995.2 _726.0 _720.0 719.4X _713.1 _714.30 696.0 _099.3 _714.0 711. OX 716.1X 716.9X _136.1 _726.61 726.33 _726.39 _726.65 726.19 726.5 Adverse Drug Reaction Adhesive Capsulitis Ankyloslng spondylitis Arthrataia. SITE Arthritis, Enteropathic Arthritis, Juvenile Arthritis, Psoriatic Arthritis, Reactive (Reiter) Arthritis, Rheumatoid Arthritis. Septic, SITE Arthritis. Traum, SITE ArthroDathv. SITE Bechets Bursitis. Anserine Bursts, Olecrano Bursitis. Other Bursitis. Prepatellar Bursitis. Subacromial Bursitis. Trochanteric Carpal Tunnel Syndrome Chondrocalcinosis. SITE Compression Fracture Spine Costochondritis Dermatomyosrtis Diabetes Mellitus Drug Monitoring Drug Monitoring, Steroid Eoicondvlitis. Lateral Epicondvlitis. Medial Fasciitis, Plantar Elevated Sed Rate Elevated Titer Fibromyalgia Fatigue arid Malaise Gout Hypercholesterolemia Hyperthyroidism Hypothyroidism * (0-9) '(0-9) * (0-9) '(0-9) * (0-9)

782.0 356.4 _446.0 725 710.4 356.9 627.8 690.1 _J24.4 723.4 443.0 726.10 _135.0 _724.3 710.1 _ 710.2 721 .0 721.3 712.2 756.12 724.0X 446.0 726.71 726.2-1 _726.1 1 726.72 726.03 727.04 727.06 _727.05 _722.51 _437.4 _446.2X 447.6 446.4 783.21

Office Procedures 20550 20551 20552 20553 20600 20605 20610 J7323 J7321 J2920 86580 Infusion J1740 J0129 J9310 J1745 J3488 Boniva Units* Orencia Units # Rituximabtf Remicade Units # Reclast Units # Inj: Tendon Sheath Lig/Gang Cyst Inj: Tendon Origin/Insert lnj:1/Mult.Triggerpt 1-2 lnj:1/Mult.Triggerpt3+ Joint Aspiration. Small Joint Aspiration. Medium Joint Aspiration. Large Euflexxa Hyalgan/Supartz. 20mg SoJumedrol. 40mg Tuberculin Skin Test

354.0 712.2X 733.12 733.6 710.3 _250.00 V58.69 V58.65 726.32 726.31 _728.71 _790.1 _795.79 _729.1 _780.79 _274.00 272.00 _242.9 244.9

Nerve Conduction 95900 95903 95904 X-Ray 73610 L R Ankle. 3 Views 77080 71020 72052 72050 Bone Density DEXA Chest, 2 views Cervical Spine. 5 vw Cervical Spine. 7 vw EA Nerve it Wave # Sensory*

73080 L R Elbow. 3 Views 73550 L R Femur, 2 Views G8553 Other Diagnosis: Return Appointment: ( Days) ( Weeks) (

"5th digit-0-unspecified; 1-shoulder; 2-upper arm; 3-forearm ; 4-hand; 5-pelvis/thigh; 6-low leg; 7-ankle/fcat; 8-other. 9 mult site PT BRINGS OWN

Referring Physician: Months) ( PRN) Doctors Signature:

Todays Fee: