CMS/EIP Fiscal Report Center: 06
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) 47 48.000000 397.4400 8.2800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 45 46.000000 477.4800 10.3800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 46 47.000000 990.7600 21.0800
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.000000 54.3800 27.1900
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 5.000000 375.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 5.000000 375.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 92 143.000000 10725.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 74 112.500000 8437.5000 75.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 22 39.000000 2925.0000 75.0000
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 2 2.000000 114.5400 57.2700
Subtotal (Total Children Is Unduplicated) 109 449.500000 24872.1000 55.3328
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EI Services,Class #03
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.000000 25.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 12 34.500000 1725.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 30 110.500000 8172.3100 73.9576
OCCT-97530HM-OT SESSION BY OT ASST 3 4.000000 710.6800 177.6700
PHY-97110-PT SESSION BY LICENSED PT 27 104.000000 8849.7400 85.0937
PHY-97110HM-PT SESSION BY PT ASST 2 3.000000 425.0000 141.6667
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 81 263.750000 18199.8700 69.0042
SPL-92508-GROUP SPL SESSION PER CHILD 1 5.000000 66.0000 13.2000
Subtotal (Total Children Is Unduplicated) 130 525.750000 38173.6000 72.6079
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Total 975.250000 63045.7000 64.6457
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Number of Children (Unduplicated) With at Least One Service 215
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Center 06
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
1138 975.250000 63045.7000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1138 975.250000 63045.7000 0.0000