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<br />ß51,ß5/2ßß3 <br /> <br />ß8:58 <br /> <br />g4g-83ß2324 <br /> <br />DENNIS COLUCCI MA <br /> <br />PAGE <br /> <br />eifel <br /> <br />Dennis A. Colucci, M.A., FAAA <br />D~nD'tlc Autllology .nd HfNrlng R~;JiQlJon <br />Board '8tfiNed I,. Audiology <br /> <br />24902 Moulton Parkway <br />Laguna Woods, Ca 92853 <br />849 830-5770 948 830-2324 FAX <br />licen... AU 348 I HA 1028 <br /> <br />Patient: <br /> <br />Date: <br /> <br />SSN: <br /> <br />DaB: <br /> <br />PhysicIan <br /> <br />M.D. UPIN: <br /> <br />Lie. <br /> <br /> <br /> <br /> <br />0 92557 Comprehensive Hearing Evaluation ) 1000 0 92582 Pediatric Evalualion 155.00 <br />0 92552 A;r Conducti(lJ1 Test 2900 0 92583 PiC(IJl't Seleclion Test 5800 <br />0 92HJ Air 8t\d Boot Conduction Tesrs 5800 0 92506 Auduory Perception Evaluation 110.00 <br />0 92562 ABLB 27.00 0 92507 Auditory Th<.r.py Number ofUnics <br /> - - <br />0 92563 Tone Decay Tcsts 2500 0 92579 Visual RcinfOrumcnt AlJdiornmy 125.00 <br />0 92565 Stenger, P\lfY: TOl'le 2600 0 92596 Ear Ptoh:ct.iOq Atttnbltor Mcuures 39.00 <br />0 92577 Speech Stonaer 47.00 0 92572 Steaa...d Spond.ic Wo,d rest (SSW) 75.00 <br />0 92567 T}'IDpaIlo",e"Y 4500 0 92576 Synlhcric Scnletlce Idcntific.ation Te't (SSI) 6/).00 <br />0 92568 Acouslic Reflexes 35.00 0 92571 Fllh::rcd Speech TC$t 4000 <br />0 92569 A..œush.c Reftn Decay 35.00 0 92589 Competin8 Speech T .,t (rCM) 45.00 <br />0 92584 Elcc:trocochleography 200.00 0 92589 Bin..,aJ Scp""'';on re" (CCM) 45.00 <br />0 92586 Audllo()' 8rainslt.m Evoked POlennals (LlITulc:d) 200 00 0 92589 Pitch Panun Percc:ptiol1 Tcst 45.00 <br />0 92585 Auditory BrairUitcm Evoked Potential, (Complex) 250.00 0 92589 Sequentilll Digits Test 45.00 <br />0 92531 R.tcorðt:d Fjstula Test 9000 0 92589 Heanng Irt Noise Test (HINT.> 4 J5000 <br />0 92541 Sponl."couS Nystagmus Tc,t, 91.00 0 69210 Cerumen Man.geMent Procedure 535 I 145 1 <br /> - <br />0 92542 Positional NystlgmU3 T esU 9200 0 99243 Consullalloo,1ix. Bxam, Deciaioo, CaJcuJauon!i 1 <br /> - <br />0 92543 BithconaJ Calories 4 18000 0 92590 Hqring Aid Ev.luadon, Monaural 15000 <br />0 92544 Opfokinetic T ellltlll 75.00 0 92591 Hearmg Aid Evaluation, Binau(&1 300.00 <br /> Oscillating nicking Tesls 6900 0 92592 Hearing Ajd ConfolTl'lity B'II8Jul.tlon. Monaural 250.00 <br /> Sinusoidal VerticallHafltolJtal Axis Rotation Tens 6 240.00 0 92593 Heacìns Aid Conformity Evalu,uion, Binaunllt 500.00 <br /> 0 92594 Elecrro-Acousric 01 probe Mic Testing, Monaural 50.00 <br /> 0 92595 ,ElcctrO-Acoustic Or P'oÐC Mic Tesling, Binaural 100.00 <br /> 0 92599 J-{c8lins Aid Cldruns MonauraJ 25.00 <br />0 2251 A,COVStic Neuroma 0 92599 Hearmg Aid CJcll1il'lg Binaural 4000 <br />0 386.02 ActJ'IIe Meniere's Dise8$c 0 <br /> 92599 Earmold, Monaural 65.00 <br />0 388.43 Auditory DtscrÍ1nnarion DefccH <br />0 38914 Central Onfheu 0 92599.22 Eamtold!, Binaural 130.00 <br />0 389.0 Conductive Hearing LOt! 0 99202 New p.tient Office V¡,it 7000 <br />0 872.8 Ear Traum8 0 99212 Repeat Office V,'II 40.00 <br />0 3818) Ew~jan Tube Dy,functlon 0 92599 '.-Hou,", Repair $l5 I 135 I 145 I 555 I SIOO <br />0 )8841 Hypeflcu,¡, <br />0 0 92599 factory RcpaJr 5200 I $l50 I $300 1$350 <br />380.4 'rn.p-,rcd Ccrumcn <br />0 3892 MiJeed Hearing Loss 0 92599 B8tterios 10 312 IJ 675 X <br />0 389.12 Ncurøl HCRin! Lo.ss 0 99002 P1oduÇ{ Dllpcn.9illg <br />0 380.1 OtitiJlExlem8 0 92599 <br />0 382.9 Olit ,Medía 0 92599 <br />0 387.2 Oto.sGler~j, <br />0 384,2 Ferion'cd Tympal'Jlc Membran~ <br />0 )89.11 Sensory Hearing Lo" CHARGES <br />0 38913 Sen.roty end Neural Hear;o8 Loss <br />0 388.31 SubjeCtIve Tlnnitu, AMOUNT PAID <br />0 3882 Sudden Sen"orineural He.ring Loss BALANCtDUE <br />0 780.4 Ve. ISC u' 'bnurn <br /> <br />