CMS/EIP Fiscal Report Center: 03
Services beginning 10/01/2011 ending 12/31/2011 Date of Report:02/16/2012 Page: 1
List order: No List
Agency Filter:EIP DEI DEIP
Payclass Filters:TPIN
Eligibility Filter:Part C (excluding not eligible)
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) 30 30.000000 248.4000 8.2800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 3 3.000000 31.1400 10.3800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 30 30.000000 632.4000 21.0800
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.000000 51.7600 51.7600
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 30.3100 30.3100
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 28 49.000000 3675.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 27 47.500000 3562.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 15 23.500000 1762.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 48.5000 48.5000
Subtotal (Total Children Is Unduplicated) 90 192.500000 10491.0100 54.4988
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 3 7.750000 526.0700 67.8800
PHY-97110-PT SESSION BY LICENSED PT 3 22.750000 1544.2700 67.8800
Subtotal (Total Children Is Unduplicated) 6 30.500000 2070.3400 67.8800
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Total 223.000000 12561.3500 56.3289
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Number of Children (Unduplicated) With at Least One Service 96
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Center 03
Flag Claims Units Chgs Paid
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R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
107 158.000000 11567.3400 0.0000
Other 65 65.000000 994.0100 0.0000
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Total 172 223.000000 12561.3500 0.0000