CMS/EIP Fiscal Report Center: 03
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Payclass Filters:OTHER
Eligibility Filter:Program Patients
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 5 5.00 43.25 8.65
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 3 3.00 31.98 10.66
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 5 5.00 104.16 20.83
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.00 28.28 28.28
Subtotal (Total Children Is Unduplicated) 5 14.00 207.67 14.83
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Total 14.00 207.67 14.83
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Number of Children (Unduplicated) With at Least One Service 5
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Center 03
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 0 0.00 0.00 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
0 0.00 0.00 0.00
Other 14 14.00 207.67 0.00
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Total 14 14.00 207.67 0.00