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: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
Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 66 66.00 582.78 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 66 66.00 712.80 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 64 64.00 1394.56 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 3.00 84.84 28.28
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 5.00 375.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 6.50 487.50 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 145 219.50 16462.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 135 197.00 14775.00 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 20 35.00 2625.00 75.00
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 4 4.00 108.88 27.22
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 9 9.00 515.43 57.27
Subtotal (Total Children Is Unduplicated) 185 675.00 38124.29 56.48
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Total 675.00 38124.29 56.48
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Number of Children (Unduplicated) With at Least One Service 185
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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
519 675.00 38124.29 0.00
Other 0 0.00 0.00 0.00
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Total 519 675.00 38124.29 0.00