CMS/EIP Fiscal Report Center: 55
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
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 10 19.500000 721.5000 37.0000
Subtotal (Total Children Is Unduplicated) 10 19.500000 721.5000 37.0000
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Screening, Eval, and Assessment,Class #02
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 9.3400 9.3400
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 21.7300 21.7300
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.000000 230.0000 115.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 7 10.936800 820.2600 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 5.470667 410.3000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 3.000000 225.0000 75.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.000000 225.0000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 5 5.000000 242.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 4 4.000000 194.0000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 8 8.582500 416.2500 48.4999
Subtotal (Total Children Is Unduplicated) 26 43.989967 2794.3800 63.5231
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 2.000000 261.9000 130.9500
OCCT-97530-OT SESSION BY LICENSED OT 17 76.815414 5214.2300 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 1 11.000000 611.0800 55.5527
PHY-97110-PT SESSION BY LICENSED PT 11 45.666984 3099.8600 67.8797
PHY-97110HM-PT SESSION BY PT ASST 4 15.204900 825.9300 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 52 272.496619 18497.0600 67.8800
Subtotal (Total Children Is Unduplicated) 70 423.183917 28510.0600 67.3704
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Total 486.673884 32025.9400 65.8058
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Number of Children (Unduplicated) With at Least One Service 90
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Center 55
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 1 1.500000 112.5000 0.0000
T 0 0.000000 0.0000 0.0000
592 485.173884 31913.4400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 593 486.673884 32025.9400 0.0000