CMS/EIP Fiscal Report Center: 06
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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 824 2529.25 93582.25 37.00
Subtotal (Total Children Is Unduplicated) 824 2529.25 93582.25 37.00
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 29 30.00 264.90 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 27 28.00 302.40 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 26 27.00 588.33 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.00 56.56 28.28
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.50 112.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.50 112.50 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 88 125.00 9375.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 90 119.50 8962.50 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 7.00 525.00 75.00
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 1 1.00 27.22 27.22
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 14 14.00 801.78 57.27
Subtotal (Total Children Is Unduplicated) 142 356.50 21128.69 59.27
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Total 2885.75 114710.94 39.75
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Number of Children (Unduplicated) With at Least One Service 827
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Center 06
Flag Claims Units Chgs Paid
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R 25 14.75 545.75 0.00
U 0 0.00 0.00 0.00
B 165 105.00 3885.00 434.75
P 3484 2242.75 83418.75 83418.75
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 0 0.00 0.00 0.00
583 523.25 26861.44 0.00
Other 0 0.00 0.00 0.00
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Total 4257 2885.75 114710.94 83853.50