CMS/EIP Fiscal Report Center: 03
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 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
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1 0.50 18.50 37.00
Subtotal (Total Children Is Unduplicated) 1 0.50 18.50 37.00
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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 3 3.00 48.90 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 37 37.00 326.71 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 16 16.00 172.80 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 35 35.00 762.65 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 3 3.00 163.14 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 6 6.00 169.68 28.28
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.00 150.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.50 83.25 55.50
Subtotal (Total Children Is Unduplicated) 41 104.50 1887.75 18.06
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 7.00 350.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 2.50 169.70 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 48.00 24.00 0.50
Subtotal (Total Children Is Unduplicated) 4 57.50 543.70 9.46
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Total 162.50 2449.95 15.08
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Number of Children (Unduplicated) With at Least One Service 45
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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
16 61.50 795.45 0.00
Other 101 101.00 1654.50 0.00
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Total 117 162.50 2449.95 0.00