CMS/EIP Fiscal Report Center: 06
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Payclass Filters:TPIN
Eligibility Filter:Not Part C
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) 80 80.00 687.50 8.59
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 79 79.00 844.80 10.69
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 81 81.00 1669.19 20.61
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 5 5.00 141.40 28.28
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 4.00 300.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 69 94.00 7050.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 54 72.00 5400.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 20 29.50 2212.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 3.00 166.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 4.50 337.50 75.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 4 4.00 243.40 60.85
Subtotal (Total Children Is Unduplicated) 106 457.00 19127.79 41.86
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EI Services,Class #03
PHY-97110-PT SESSION BY LICENSED PT 1 1.50 101.82 67.88
Subtotal (Total Children Is Unduplicated) 1 1.50 101.82 67.88
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Total 458.50 19229.61 41.94
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Number of Children (Unduplicated) With at Least One Service 106
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Center 06
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
405 458.50 19229.61 0.00
Other 0 0.00 0.00 0.00
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Total 405 458.50 19229.61 0.00