CMS/EIP Fiscal Report Center: 06
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-92555-SPEECH AUD THRESHOLD (DETECTION) 56 56.00 494.48 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 55 55.00 594.00 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 54 54.00 1176.66 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.00 28.28 28.28
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.50 262.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 6.00 450.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 114 157.50 11812.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 99 139.00 10425.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.00 55.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 13 22.00 1650.00 75.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 10 10.00 572.70 57.27
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 179 506.00 27570.12 54.49
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 5.00 250.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 41 177.00 13457.25 76.03
PHY-97110-PT SESSION BY LICENSED PT 54 201.00 13643.88 67.88
PHY-97110HM-PT SESSION BY PT ASST 4 12.00 651.84 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 166 637.75 40886.31 64.11
SPL-92508-GROUP SPL SESSION PER CHILD 3 6.00 79.20 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 25.00 12.50 0.50
Subtotal (Total Children Is Unduplicated) 226 1063.75 68980.98 64.85
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Total 1569.75 96551.10 61.51
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Number of Children (Unduplicated) With at Least One Service 362
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Center 06
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
1814 1569.75 96551.10 0.00
Other 0 0.00 0.00 0.00
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Total 1814 1569.75 96551.10 0.00