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<br />Dennis A. Colucci, Au.D., M.A. FAAA <br />Auditory Disorders and Balance Labo11Jtory <br />Board Cerlif1ed In Audiology <br /> <br />Patient: <br /> <br />Date: <br /> <br />23961 Calle De La Magdalena, Suite 355 <br />Laguna Hills, Ca 92653 <br />949 830.5770 949 830.2324 FAX <br />l.icenses AU 348 I HA 1026 <br /> <br />SSN: <br /> <br />Physician <br /> <br />DaB: <br /> <br />M.D. UPIN: <br /> <br />Lie. <br /> <br />0 314,Q AD!) - AUe:ntion Deficit Uisorder <br />0 314.01 ADHD. AI1e-otion Deficit Hyperactivity Disorder <br />0 7&4.3 Aphasia <br />0 299,0 Autism <br />0 389.14 Central Hearing l,Oss <br />0 315.39 Delayed Speech Development <br />0 38Q.4\ Ear wax <br />0 382.9 OtitisM:dia <br /> CHARGES <br />0 JR9.12 Sensorineural Hearing loss! Neural <br />0 AMOUNT PAID <br />389.tl Sensorinerual Hearing Loss! Sensory <br />0 Other RALANCE DUE <br /> <br />CPT Code Description No Fee <br /> <br /> Pediatric Testing <br />0 92582 Pediatric Evaluation 80.00 <br />0 925R3 Picture Selection Test 58.00 <br />0 92506 Auditory Perception Evuhmtion 110.00 <br />0 92507 Auditory Therapy Number of Units - -- <br />0 92579 Visual RcinforccJIlt"nt Audiometry 125,00 <br />0 92557 Comprehenslve Hearing Evaluation 17500 <br />0 92552 Air Conduction Test 29.00 <br />0 9255J Air and Bone Conductiol.t Te:;ts 58,00 <br />0 92562 ABLB 27.00 <br />0 92563 Tone Decay Tests 25,00 <br />0 92565 Strnger, Pure Tone 26.00 <br />0 92571 Speecn Stenger 47.00 <br />0 92567 Tympanometry 45.00 <br />U 91568 Acoustic Reflexes 35.00 <br />0 92569 Acoustic Reflex Decay 35.00 <br />0 92584 Ekcuocochleograplly 200.00 <br />0 92586 Al.ldilory Brailt.'ltcm Evoked Potentials (Limited) 250.00 <br />0 91585 Al.ldilory Brainstem f:vGk~d Potentials tComplex) 300.00 <br />0 <br /> <br />DiagnosIs Code Descnptlon <br /> <br />CPT Code Description No Fee <br /> <br /> Central Auditory Procl!ssing Te.<ih <br />0 92700 Childrens's Auditory Perfonnancc Scale 45,()() <br />0 92700 Pcdiatric Development Scalc 45.00 <br />0 99243 COll~\.Iltil.li\ll1, Hx, Exam, Decision, Calculations <br />0 92572 Staggered Spondaic Wurd Test (SSW) 75.00 <br />0 9257(; Synthetic Sentence Identificatiol\ Test (SSI) <br />0 92511 PiheJcu Word Test 45.00 <br />0 92700 Competing Word Test 45.00 <br />[J 92700 Competing Sentence Test 45.00 <br />0 92700 Auditory rigure Ground 45.00 <br />0 92700 Pitch Pattcrn Perceplion Test 45,UU <br />0 92700 Timc Compressed Speech 55.00 <br />0 92700 HINT Quiet 45,00 <br />0 92700 HiNT Noise Front 45.00 <br />0 92700 HINT Noise Right 45,00 <br />0 92700 HINT Noise Left 45.00 <br />0 92700 Dichotic Digit~ Single Pair~ 45.00 <br />0 92700 Dichotic Digits Doubk Pairs 50.00 <br />0 92700 Random Gap Detection 50.00 <br />0 92700 Masking Levcl DiflCrence 45.00 <br />0 92700 WIP[ Word ldentiflCation (Noise) 65.00 <br />0 <br /> NOTES <br />