CMS/EIP Fiscal Report Center: 06
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Payclass Filters:TPIN
Eligibility Filter:Not Part C
List order: No List
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) 17 17.00 150.11 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 18 18.00 194.40 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 19 19.00 414.01 21.79
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 2.50 187.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 15 16.50 1237.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 14 16.50 1237.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 8.50 637.50 75.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.00 57.27 57.27
Subtotal (Total Children Is Unduplicated) 26 100.00 4190.79 41.91
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Total 100.00 4190.79 41.91
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Number of Children (Unduplicated) With at Least One Service 26
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Center 06
Flag Claims Units Chgs Paid
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R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
93 100.00 4190.79 0.00
Other 0 0.00 0.00 0.00
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Total 93 100.00 4190.79 0.00