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: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-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 9 16.50 1237.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 7 11.50 862.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 5.50 412.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 7.50 562.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 9 15.50 860.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 109 182.50 13687.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 68 118.00 8850.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 39 67.00 5025.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 129 240.50 13347.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 42 58.00 4350.00 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) 211 749.50 50135.75 66.89
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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 159 516.75 34705.52 67.16
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 5 13.00 703.57 54.12
Subtotal (Total Children Is Unduplicated) 262 1392.75 92894.80 66.70
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Total 2142.25 143030.55 66.77
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Number of Children (Unduplicated) With at Least One Service 443
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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
1282 2142.25 143030.55 0.00
Other 0 0.00 0.00 0.00
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Total 1282 2142.25 143030.55 0.00