CMS/EIP Fiscal Report Center: 06
Services beginning 04/01/2010 ending 06/30/2010 Date of Report:08/18/2010 Page: 1
Payclass Filters:MED
Eligibility Filter:DEI Only
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 52 165.50 6123.50 37.00
Subtotal (Total Children Is Unduplicated) 52 165.50 6123.50 37.00
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 2 2.00 17.66 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.00 21.60 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.00 43.58 21.79
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 6.00 450.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 6.50 487.50 75.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.00 57.27 57.27
Subtotal (Total Children Is Unduplicated) 6 19.50 1077.61 55.26
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4 17.00 850.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 2 11.00 746.68 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 6.00 407.28 67.88
Subtotal (Total Children Is Unduplicated) 8 34.00 2003.96 58.94
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Total 219.00 9205.07 42.03
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Number of Children (Unduplicated) With at Least One Service 52
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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 224 147.75 5466.75 0.00
P 20 16.25 601.25 601.25
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
58 55.00 3137.07 0.00
Other 0 0.00 0.00 0.00
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Total 302 219.00 9205.07 601.25