CMS/EIP Fiscal Report Center: 06
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Agency Filter:EIP DEI DEIP
Payclass Filters:TPIN
Eligibility Filter:Part C (excluding not eligible)
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 1 0.75 27.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 3 3.75 138.75 37.00
Subtotal (Total Children Is Unduplicated) 4 4.50 166.50 37.00
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 105 105.00 927.15 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 99 99.00 1069.20 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 99 99.00 2157.21 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 11 11.00 311.08 28.28
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 115 178.00 13350.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 50 75.00 5625.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 53 84.00 6300.00 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 7.00 525.00 75.00
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 6 6.00 163.32 27.22
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 19 19.00 1088.13 57.27
MED-99212-OUTPATIENT VISIT, EST, 10 MINS 1 1.00 18.17 18.17
Subtotal (Total Children Is Unduplicated) 149 684.00 31534.26 46.10
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Total 688.50 31700.76 46.04
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Number of Children (Unduplicated) With at Least One Service 153
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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
567 688.50 31700.76 0.00
Other 0 0.00 0.00 0.00
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Total 567 688.50 31700.76 0.00