CMS/EIP Fiscal Report Center: 03
Services beginning 10/01/2012 ending 12/31/2012 Date of Report:02/16/2013 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) 18 19.000000 173.0900 9.1100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 8 8.000000 74.7200 9.3400
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 20 21.000000 456.3300 21.7300
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 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 29 48.000000 3600.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 26 45.000000 3375.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 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) 70 153.000000 8513.6400 55.6447
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 7 36.000000 1439.7900 39.9942
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 21.000000 1050.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 5 19.000000 1289.7200 67.8800
PHY-97110-PT SESSION BY LICENSED PT 1 1.000000 67.8800 67.8800
Subtotal (Total Children Is Unduplicated) 15 77.000000 3847.3900 49.9661
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Total 230.000000 12361.0300 53.7436
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Number of Children (Unduplicated) With at Least One Service 83
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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
110 182.000000 11656.8900 0.0000
Other 48 48.000000 704.1400 0.0000
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Total 158 230.000000 12361.0300 0.0000