CMS/EIP Fiscal Report Center: 10
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Payclass Filters:TPIN
Eligibility Filter:Part C (excluding not eligible)
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 2 2.00 21.24 10.62
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 2 2.00 17.66 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.00 21.18 10.59
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 4 4.00 87.16 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 3.00 84.84 28.28
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 9 12.00 900.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 3.50 262.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 4.50 337.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 6 9.00 675.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 7 13.00 721.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 62 109.50 8212.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 43 79.00 5925.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 24 41.50 3112.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 41 77.00 4273.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 41 60.00 4500.00 75.00
Subtotal (Total Children Is Unduplicated) 110 422.00 29152.08 69.08
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 3.00 150.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 92 344.25 23327.01 67.76
OCCT-97530HM-OT SESSION BY OT ASST 5 10.50 570.36 54.32
PHY-97110-PT SESSION BY LICENSED PT 108 373.00 25319.24 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 161 543.50 36892.78 67.88
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 6 10.00 543.20 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 3 5.00 66.00 13.20
Subtotal (Total Children Is Unduplicated) 241 1289.25 86868.59 67.38
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Total 1711.25 116020.67 67.80
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Number of Children (Unduplicated) With at Least One Service 328
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Center 10
Flag Claims Units Chgs Paid
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R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 1 1.50 101.82 0.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
1027 1709.75 115918.85 0.00
Other 0 0.00 0.00 0.00
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Total 1028 1711.25 116020.67 0.00