CMS/EIP Fiscal Report Center: 07
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) 4 5.000000 41.4000 8.2800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.000000 20.7600 10.3800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 3 3.000000 63.2400 21.0800
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 1 2.000000 45.9200 22.9600
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.000000 51.7600 51.7600
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 27.1900 27.1900
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 2 3.000000 90.9300 30.3100
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 5.000000 375.0000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 2.000000 97.0000 48.5000
SENS-V5014TS-HEARING AID REPAIR IN-OFFICE 1 1.000000 15.0000 15.0000
Subtotal (Total Children Is Unduplicated) 12 25.000000 828.2000 33.1280
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 21 125.750000 6287.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 6 22.000000 1493.3600 67.8800
PHY-97110-PT SESSION BY LICENSED PT 1 2.000000 135.7600 67.8800
SENS-V5264-EARMOLD 1 1.000000 18.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 11 54.500000 3699.4600 67.8800
Subtotal (Total Children Is Unduplicated) 38 205.250000 11634.0800 56.6825
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Total 230.250000 12462.2800 54.1250
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Number of Children (Unduplicated) With at Least One Service 48
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Center 07
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 12 36.000000 1978.8000 1978.8000
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
96 194.250000 10483.4800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 108 230.250000 12462.2800 1978.8000