CMS/EIP Fiscal Report Center: 03
Services beginning 10/01/2013 ending 12/31/2013 Date of Report:02/18/2014 Page: 1
List order: No List
Payclass Filters:TPIN
Eligibility Filter:Part C (excluding not eligible)
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) 25 26.000000 248.6900 9.5650
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 11 11.000000 97.1600 8.8327
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 25 26.000000 555.4900 21.3650
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.000000 56.9400 56.9400
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.000000 46.4900 23.2450
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 5.500000 412.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 15 27.500000 2062.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 26 42.500000 3187.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 26 43.500000 3262.5000 75.0000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 48.5000 48.5000
Subtotal (Total Children Is Unduplicated) 87 190.000000 10278.2700 54.0962
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
PHY-97110-PT SESSION BY LICENSED PT 10 44.250000 3003.6900 67.8800
Subtotal (Total Children Is Unduplicated) 10 44.250000 3003.6900 67.8800
-----------------------------------------------------------------------------------------------------------------------
Total 234.250000 13281.9600 56.6999
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 95
-----------------------------------------------------------------------------------------------------------------------
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
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
121 168.250000 12277.1900 0.0000
Other 66 66.000000 1004.7700 0.0000
---------------------------------------------------------
Total 187 234.250000 13281.9600 0.0000