CMS/EIP Fiscal Report Center: 03
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 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-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.00 16.30 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 39 39.00 344.37 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 13 13.00 140.40 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 41 41.00 893.39 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.00 28.28 28.28
Subtotal (Total Children Is Unduplicated) 43 95.00 1422.74 14.98
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 5.00 250.00 50.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 14.00 7.00 0.50
Subtotal (Total Children Is Unduplicated) 1 19.00 257.00 13.53
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Total 114.00 1679.74 14.73
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Number of Children (Unduplicated) With at Least One Service 44
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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
6 19.00 257.00 0.00
Other 95 95.00 1422.74 0.00
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Total 101 114.00 1679.74 0.00