CMS/EIP Fiscal Report Center: 06
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 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 710 2327.75 86126.75 37.00
Subtotal (Total Children Is Unduplicated) 710 2327.75 86126.75 37.00
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 43 43.00 379.69 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 43 43.00 464.40 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 41 41.00 893.39 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 4 4.00 113.12 28.28
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 10.50 787.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 6 9.50 712.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.50 112.50 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 108 161.00 12075.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 98 150.00 11250.00 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 13 22.50 1687.50 75.00
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 1 1.00 27.22 27.22
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 10 10.00 572.70 57.27
Subtotal (Total Children Is Unduplicated) 145 497.00 29075.52 58.50
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Total 2824.75 115202.27 40.78
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Number of Children (Unduplicated) With at Least One Service 713
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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 1434 1046.25 38711.25 582.75
P 1376 1065.50 46985.50 46948.00
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
912 713.00 29505.52 0.00
Other 0 0.00 0.00 0.00
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Total 3722 2824.75 115202.27 47530.75