CMS/EIP Fiscal Report Center: 10
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 15 16.00 174.17 10.89
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 15 16.00 145.20 9.08
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 14 15.00 168.75 11.25
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 9 9.00 198.82 22.09
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 5 5.00 141.40 28.28
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 44 69.00 5175.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 22 34.00 2550.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 23 35.00 2625.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 22 36.50 2737.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 44 80.00 4440.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 366 633.00 47475.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 205 351.00 26325.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 167 252.00 18900.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 336 589.50 32717.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 194 287.00 21525.00 75.00
Subtotal (Total Children Is Unduplicated) 652 2428.00 165298.09 68.08
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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 179 1323.75 89764.62 67.81
OCCT-97530HM-OT SESSION BY OT ASST 8 44.00 2390.08 54.32
PHY-97110-PT SESSION BY LICENSED PT 192 1483.25 100703.39 67.89
PHY-97110HM-PT SESSION BY PT ASST 1 1.50 81.48 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 302 2029.00 137728.52 67.88
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 10 41.50 2294.96 55.30
SPL-92508-GROUP SPL SESSION PER CHILD 3 4.00 52.80 13.20
Subtotal (Total Children Is Unduplicated) 442 4930.00 333165.85 67.58
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Total 7358.00 498463.94 67.74
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Number of Children (Unduplicated) With at Least One Service 951
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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
4318 7356.50 498362.12 0.00
Other 0 0.00 0.00 0.00
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Total 4319 7358.00 498463.94 0.00