CMS/EIP Fiscal Report Center: 03
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/17/2009 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 1 1.00 10.62 10.62
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.00 16.30 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 28 28.00 247.24 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 9 9.00 97.20 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 28 28.00 610.12 21.79
Subtotal (Total Children Is Unduplicated) 30 67.00 981.48 14.65
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Total 67.00 981.48 14.65
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Number of Children (Unduplicated) With at Least One Service 30
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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 67 67.00 981.48 0.00
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Total 67 67.00 981.48 0.00