CMS/EIP Fiscal Report Center: 10
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 Page: 1
Payclass Filters:TPIN
Eligibility Filter:Part C (excluding not eligible)
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 1 1.00 10.62 10.62
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.00 16.30 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 2.00 17.66 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 2.00 20.76 10.38
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 2.00 43.58 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 2.00 56.56 28.28
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.00 100.23 50.12
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 4.50 337.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.50 262.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 3.50 262.50 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 2 3.50 194.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 68 116.50 8737.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 45 83.50 6262.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 24 43.00 3225.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 66 127.00 7048.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 24 36.50 2737.50 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 4 5.00 203.04 40.61
PSTH-97001-EVAL BY LICENSED PT, INITIAL 3 3.00 145.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 7 7.00 326.00 46.57
Subtotal (Total Children Is Unduplicated) 125 453.50 30383.00 67.00
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 10.00 1187.92 118.79
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 6.00 300.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 98 395.50 26517.11 67.05
OCCT-97530HM-OT SESSION BY OT ASST 5 7.00 379.68 54.24
PHY-97110-PT SESSION BY LICENSED PT 130 444.50 29101.00 65.47
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 158 516.25 34621.20 67.06
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 5 13.00 703.57 54.12
Subtotal (Total Children Is Unduplicated) 261 1392.25 92810.48 66.66
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Total 1845.75 123193.48 66.74
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Number of Children (Unduplicated) With at Least One Service 357
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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
1100 1845.75 123193.48 0.00
Other 0 0.00 0.00 0.00
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Total 1100 1845.75 123193.48 0.00