CMS/EIP Fiscal Report Center: 06
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 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 638 2018.00 74666.00 37.00
Subtotal (Total Children Is Unduplicated) 638 2018.00 74666.00 37.00
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 43 44.00 388.52 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 42 43.00 464.40 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 42 43.00 936.97 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 3.00 84.84 28.28
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 7.50 562.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 7.50 562.50 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 75 121.50 9112.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 74 115.50 8662.50 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.50 112.50 75.00
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 2 2.00 54.44 27.22
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 4 4.00 229.08 57.27
MED-99212-OUTPATIENT VISIT, EST, 10 MINS 1 1.00 18.17 18.17
Subtotal (Total Children Is Unduplicated) 100 393.50 21188.92 53.85
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Total 2411.50 95854.92 39.75
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Number of Children (Unduplicated) With at Least One Service 641
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Center 06
Flag Claims Units Chgs Paid
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R 8 4.00 148.00 111.00
U 0 0.00 0.00 0.00
B 1807 1251.00 46287.00 0.00
P 747 487.75 18046.75 18046.75
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 1 0.25 9.25 0.00
753 668.50 31363.92 0.00
Other 0 0.00 0.00 0.00
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Total 3316 2411.50 95854.92 18157.75