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: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) 67 67.00 591.61 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 68 68.00 734.40 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 67 67.00 1459.93 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 2.00 150.00 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 119 169.50 12712.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 99 149.00 11175.00 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 11.00 825.00 75.00
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 2 2.00 54.44 27.22
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 7 7.00 400.89 57.27
Subtotal (Total Children Is Unduplicated) 156 545.00 28197.83 51.74
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Total 545.00 28197.83 51.74
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Number of Children (Unduplicated) With at Least One Service 156
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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
441 545.00 28197.83 0.00
Other 0 0.00 0.00 0.00
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Total 441 545.00 28197.83 0.00