CMS/EIP Fiscal Report Center: 10
Services beginning 10/01/2008 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 6 6.00 63.72 10.62
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 6 6.00 52.98 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 5 5.00 54.00 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.00 21.79 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.00 28.28 28.28
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 9 15.50 1162.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 6 12.00 900.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 7 10.50 787.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 5.00 375.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 6.00 333.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 125 226.50 16987.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 75 130.00 9750.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 44 64.50 4837.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 47 77.00 4273.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 50 74.50 5587.50 75.00
Subtotal (Total Children Is Unduplicated) 169 640.50 45214.77 70.59
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 65 171.75 11658.39 67.88
OCCT-97530HM-OT SESSION BY OT ASST 2 4.50 244.44 54.32
PHY-97110-PT SESSION BY LICENSED PT 82 214.50 14560.26 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 116 283.25 19227.01 67.88
Subtotal (Total Children Is Unduplicated) 190 674.00 45690.10 67.79
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Total 1314.50 90904.87 69.16
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Number of Children (Unduplicated) With at Least One Service 348
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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 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
769 1314.50 90904.87 0.00
Other 0 0.00 0.00 0.00
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Total 769 1314.50 90904.87 0.00