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
Payclass Filters:TPIN
Eligibility Filter:Program Patients
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) 34 34.000000 281.5200 8.2800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 4 4.000000 41.5200 10.3800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 35 35.000000 737.8000 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 2 3.000000 225.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 46 75.000000 5625.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 42 69.000000 5175.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 22 35.500000 2662.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 5.500000 305.2500 55.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 48.5000 48.5000
Subtotal (Total Children Is Unduplicated) 129 267.000000 15409.1600 57.7122
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 5.000000 250.0000 50.0000
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
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 8.000000 543.0400 67.8800
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 40.000000 20.0000 0.5000
Subtotal (Total Children Is Unduplicated) 9 83.500000 2883.3800 34.5315
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Total 350.500000 18292.5400 52.1898
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Number of Children (Unduplicated) With at Least One Service 138
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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
164 275.500000 17149.6300 0.0000
Other 75 75.000000 1142.9100 0.0000
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Total 239 350.500000 18292.5400 0.0000