CMS/EIP Fiscal Report Center: 06
Services beginning 01/01/2010 ending 03/31/2010 Date of Report:05/17/2010 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 843 2812.75 104071.75 37.00
Subtotal (Total Children Is Unduplicated) 843 2812.75 104071.75 37.00
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 46 46.00 406.18 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 46 46.00 496.80 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 44 44.00 958.76 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.00 56.56 28.28
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 4.00 300.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 5.00 375.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 0.50 37.50 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 98 134.50 10087.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 77 112.50 8437.50 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 4.50 337.50 75.00
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 1 1.00 27.22 27.22
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 4 4.00 229.08 57.27
Subtotal (Total Children Is Unduplicated) 128 404.00 21749.60 53.84
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Total 3216.75 125821.35 39.11
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Number of Children (Unduplicated) With at Least One Service 843
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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 1538 961.25 35566.25 129.50
P 2688 1758.25 65055.25 65055.25
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
480 497.25 25199.85 0.00
Other 0 0.00 0.00 0.00
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Total 4706 3216.75 125821.35 65184.75