CMS/EIP Fiscal Report Center: 03
Services beginning 01/01/2010 ending 03/31/2010 Date of Report:05/17/2010 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 1 1.00 16.30 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 24 24.00 211.92 8.83
AUDE-92557-COMP AUDIO THRESHOLD EVAL/SPCH RECOG 1 1.00 27.10 27.10
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 7 7.00 75.60 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 23 23.00 501.17 21.79
Subtotal (Total Children Is Unduplicated) 25 56.00 832.09 14.86
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 8.00 400.00 50.00
Subtotal (Total Children Is Unduplicated) 1 8.00 400.00 50.00
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Total 64.00 1232.09 19.25
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Number of Children (Unduplicated) With at Least One Service 26
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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
8 8.00 400.00 0.00
Other 56 56.00 832.09 0.00
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Total 64 64.00 1232.09 0.00