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: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
TCM-T1017TL-TARGETED CASE MANAGEMENT 1 0.25 37.00 148.00
Subtotal (Total Children Is Unduplicated) 1 0.25 37.00 148.00
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 54 54.00 476.82 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 54 54.00 583.20 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 54 54.00 1176.66 21.79
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 8 13.00 975.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 8 12.50 937.50 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 116 181.50 13612.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 108 163.50 12262.50 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 14.50 1087.50 75.00
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 1 1.00 27.22 27.22
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 16 16.00 916.32 57.27
Subtotal (Total Children Is Unduplicated) 149 564.00 32055.22 56.84
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Total 564.25 32092.22 56.88
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Number of Children (Unduplicated) With at Least One Service 150
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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
428 564.25 32092.22 0.00
Other 0 0.00 0.00 0.00
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Total 428 564.25 32092.22 0.00