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: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) 55 55.00 485.65 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 54 54.00 583.20 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 53 53.00 1154.87 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.00 28.28 28.28
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.50 262.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 6.00 450.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 87 126.50 9487.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 75 112.00 8400.00 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 18.00 1350.00 75.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 10 10.00 572.70 57.27
Subtotal (Total Children Is Unduplicated) 145 439.00 22774.70 51.88
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Total 439.00 22774.70 51.88
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Number of Children (Unduplicated) With at Least One Service 145
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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
351 439.00 22774.70 0.00
Other 0 0.00 0.00 0.00
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Total 351 439.00 22774.70 0.00