CMS/EIP Fiscal Report Center: 10
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-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.000000 13.0500 13.0500
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.000000 0.9900 0.9900
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.000000 9.1100 9.1100
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.000000 25.8900 12.9450
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 10 16.500000 1237.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 7 12.000000 900.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 5.000000 375.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 10 16.500000 915.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 113 193.000000 14475.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 41 69.500000 5212.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 31 52.500000 3937.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 124 237.000000 13153.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 53 83.000000 6225.0000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 6 6.000000 290.5000 48.4167
SPCH-92506-SPEECH EVAL BY LICENSED SLP 2 2.000000 63.5000 31.7500
Subtotal (Total Children Is Unduplicated) 196 698.000000 46834.7900 67.0986
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 4 32.000000 3456.4600 108.0144
OCCT-97530-OT SESSION BY LICENSED OT 45 169.000000 11137.9800 65.9052
OCCT-97530HM-OT SESSION BY OT ASST 4 20.000000 988.3200 49.4160
PHY-97110-PT SESSION BY LICENSED PT 77 283.250000 18457.9500 65.1649
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 57 182.000000 12098.2400 66.4738
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 2 3.000000 162.9600 54.3200
Subtotal (Total Children Is Unduplicated) 143 689.250000 46301.9100 67.1772
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Total 1387.250000 93136.7000 67.1376
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Number of Children (Unduplicated) With at Least One Service 309
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Center 10
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
772 1387.250000 93136.7000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 772 1387.250000 93136.7000 0.0000