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: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 0.50 18.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 3 6.75 249.75 37.00
Subtotal (Total Children Is Unduplicated) 4 7.25 268.25 37.00
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 45 45.00 397.35 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 44 44.00 475.20 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 44 44.00 958.76 21.79
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 9.50 712.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.50 262.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 6.00 450.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 118 186.00 13950.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 77 118.50 8887.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 58 99.00 7425.00 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 11 11.00 629.97 57.27
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 4 4.00 138.00 34.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 2 2.00 97.00 48.50
Subtotal (Total Children Is Unduplicated) 147 583.00 34974.94 59.99
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Total 590.25 35243.19 59.71
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Number of Children (Unduplicated) With at Least One Service 151
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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
428 590.25 35243.19 0.00
Other 0 0.00 0.00 0.00
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Total 428 590.25 35243.19 0.00