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<br />Dennis A. Colucci, Au.D., M.A., FAAA <br />Audllory Disorders .rld Balance LaboJlltory <br />Board Certified 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 949830-2324 FAX <br />Licenses Au 3481 HA 1026 <br /> <br />SSN: <br /> <br />DOB: <br /> <br />Physician <br /> <br />M.D. UPIN: <br /> <br />Lie. <br /> <br /> <br />0 92557 Comprehensive Hearing Evaluation 175,00 0 92582 Pediatric Evaluation 80,00 <br />0 92552 Air Conduction Test 29,00 0 9251U Picture Selection Test 58,00 <br />0 92553 Air and Rone Conduction Tests 58.00 0 92620 Central Auditory Processing Evaluation 150.00 <br />0 92562 ABLB 27.00 0 92621 Central Auditory Processing Eva!. Number of Units <br /> - - <br />0 92563 Tone Decay Tests 25.00 0 92579 Visual Reinforcement Audiometry 125.00 <br />0 92565 Stenger, Pure Tone 26.00 0 92596 Far Protection Attenuator Measures 39.00 <br />0 92517 Speech Stenger 47.00 0 92625 k>sessment of Tinnitus 45.00 <br />[J 92567 Tympanomctry 45.00 [] 92700 Hearing in Noise Test (HINT) 4 180.00 <br />0 92568 ^coustic Reflexes 35.00 0 6921(l Cerumen Management procedure $45 I $55 <br />0 92569 Acoustic Reflex Decay 35.00 0 99243 Consultation, Hx, Exam, Decision, Calculations <br />0 92584 F.1ectrocochleography 250.00 0 92590 Hearing Aid Evaluation, Monaural 75.00 <br />0 92586 Auditory Drainstem Evoked Potentials (Limited) 250.00 0 92591 Ht:aring Aid Evaluation, Bimtural 150.00 <br />[J 92585 Auditory Rrainslcm Evoked Pott:ntials (Complex) 350.00 0 92592 Hearing Aid Confonnity Evaluation, Monaural 75_00 <br />0 92531 Recorded Fistula Test 90.00 0 92593 Hearing Aid Conionnity Evaluation. Binaural 150.00 <br />0 92541 Sponlaneous Nystagmus Tests 91.00 0 92594 Electro-Acullstic or Probe Mic. Testing, Monaural 50.00 <br />0 92542 Positional Nystagmus Tests 92.00 0 92595 Electro-Acoustic or Probe Mic. Testing, Billaural 100.00 <br />0 92543 Bithennal Calories 4 180.00 0 V5011 1 learing Aid Cleaning Monaural 45.00 <br />0 92S44 OplokineticTcsts 15.00 0 VSOII Hearing Aid Cleaning Binaural 90.00 <br />[] 9254S oscillating Tracking Tests 69.00 0 VS264 Eannold Monaurnl or Binaural $ISU/$300 <br />0 92546 Sinusoidal Vt:rtical/Tlorirontal Axis Rorntioll Tests 6 330.00 U V5110 Dispt:ming Fee 200 / 3001 4001 5001 600 <br />0 92547 0 99202 New patknt Office Visit 70.00 <br /> 0 99212 Kepeat Office Visit 40.00 <br /> 0 V50t4 In-I louse Repair $25 I $351 $45 I $SS I $100 <br />0 225.1 Acoustic Neuroma 0 V5014 Factory Repair $200 I $250 I $30U ! $350 <br />0 386.02 Active Menierc'sDisease 0 <br /> VS266 Balterie& 10 312 13 615 x <br />0 388.43 Auditory Discrimnation Defel:il <br /> 0 99002 Product Dispensing ~ <br />0 389.14 Central Dt:afiless <br />0 389.0 Conductive Hearing Loss 0 V509<l Dispensing <br />0 812.8 Ear Trauma 0 92588 Otoacoustic Emissiuns 150.00 <br />0 381.81 Eu&tachian Tuhe Dysfunction 0 92100 <br />0 388.41 Hyperacusis 0 <br /> 92700 <br />U 38004 Impacted Cerumen <br />0 389.2 Mixed Hearing Loss 0 92700 <br />0 389.12 Neural Hearing Loss NOTES <br />0 380.1 Otitis Externa <br />U 382.9 OtilisMedia <br />0 387.2 Otosclerosis <br />0 384.2 Perforalt:d Tympanic Membrane <br />0 389.11 Sensory Hearing Loss C1IARGES <br />U 389.10 Sensory Hearing Loss _Unspcciticd <br />0 388.31 Subjective Tinnitus AMOUNT PAID - - <br />0 388.2 Sudden Sensorineural Hearing Loss BALANCE DUE <br />0 7S004 Verti oIDise uilibrium <br /> <br /> <br />