CMS/EIP Fiscal Report Center: 06
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Agency Filter:EIP DEI DEIP
Payclass Filters:MED
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
TCM-T1017TL-TARGETED CASE MANAGEMENT 1086 6637.50 245565.75 37.00
Subtotal (Total Children Is Unduplicated) 1086 6637.50 245565.75 37.00
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 318 329.00 2850.17 8.66
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 279 290.00 3109.74 10.72
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 268 280.00 5861.70 20.93
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 38 38.00 1067.01 28.08
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 10.00 750.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 11 17.00 1275.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 4.50 337.50 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 176 265.00 19875.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 155 233.00 17475.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 97 142.50 10687.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.00 55.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 14.50 1087.50 75.00
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 14 14.00 387.87 27.71
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 36 36.00 2204.92 61.25
MED-99212-OUTPATIENT VISIT, EST, 10 MINS 3 3.00 54.51 18.17
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 5 5.00 172.50 34.50
Subtotal (Total Children Is Unduplicated) 410 1682.50 67251.42 39.97
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Total 8320.00 312817.17 37.60
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Number of Children (Unduplicated) With at Least One Service 1088
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Center 06
Flag Claims Units Chgs Paid
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R 2 1.50 55.50 0.00
U 0 0.00 0.00 0.00
B 6094 3983.75 147377.00 1535.50
P 3753 2445.75 90492.75 90492.75
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
1790 1889.00 74891.92 9.25
Other 0 0.00 0.00 0.00
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Total 11639 8320.00 312817.17 92037.50