CMS/EIP Fiscal Report Center: 06
Services beginning 10/01/2008 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 617 1571.25 58114.50 36.99
Subtotal (Total Children Is Unduplicated) 617 1571.25 58114.50 36.99
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 33 33.00 291.39 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 31 31.00 334.80 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 30 30.00 653.70 21.79
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 2.50 187.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 2.50 187.50 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 65 101.50 7612.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 53 83.50 6262.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 27 43.50 3262.50 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 5.50 412.50 75.00
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 3 3.00 81.66 27.22
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 9 9.00 515.43 57.27
MED-99212-OUTPATIENT VISIT, EST, 10 MINS 2 2.00 36.34 18.17
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 1 1.00 34.50 34.50
Subtotal (Total Children Is Unduplicated) 84 348.00 19872.82 57.11
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Total 1919.25 77987.32 40.63
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Number of Children (Unduplicated) With at Least One Service 619
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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 2191 1436.25 53119.50 83.25
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
462 483.00 24867.82 0.00
Other 0 0.00 0.00 0.00
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Total 2653 1919.25 77987.32 83.25