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:TPIN
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-92552-PURE TONE AUDIOMETRY -AIR ONLY 3 3.00 31.86 10.62
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 3 3.00 45.38 15.13
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 131 135.00 1160.55 8.60
AUDE-92557-COMP AUDIO THRESHOLD EVAL/SPCH RECOG 1 1.00 27.10 27.10
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 56 57.00 608.04 10.67
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 128 132.00 2713.42 20.56
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 3 3.00 163.14 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 9 9.00 253.43 28.16
Subtotal (Total Children Is Unduplicated) 136 343.00 5002.92 14.59
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Total 343.00 5002.92 14.59
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Number of Children (Unduplicated) With at Least One Service 136
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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 343 343.00 5002.92 0.00
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Total 343 343.00 5002.92 0.00