CMS/EIP Fiscal Report Center: 03
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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 2 2.00 32.60 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 25 25.00 220.75 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 9 9.00 97.20 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 24 24.00 522.96 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.00 54.38 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.00 28.28 28.28
Subtotal (Total Children Is Unduplicated) 27 62.00 956.17 15.42
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EI Services,Class #03
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 1.00 50.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 12.00 400.00 33.33
OCCT-97530-OT SESSION BY LICENSED OT 1 3.50 237.58 67.88
PHY-97110-PT SESSION BY LICENSED PT 2 4.50 305.46 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 3.00 203.64 67.88
Subtotal (Total Children Is Unduplicated) 4 24.00 1196.68 49.86
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Total 86.00 2152.85 25.03
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Number of Children (Unduplicated) With at Least One Service 31
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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
25 24.00 1196.68 0.00
Other 62 62.00 956.17 0.00
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Total 87 86.00 2152.85 0.00