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:Not Part C
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 39 166.00 6142.00 37.00
Subtotal (Total Children Is Unduplicated) 39 166.00 6142.00 37.00
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Screening, Eval, and Assessment,Class #02
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.00 10.80 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.00 21.79 21.79
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 12 13.50 1012.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 12 15.50 1162.50 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.00 150.00 75.00
Subtotal (Total Children Is Unduplicated) 18 33.00 2357.59 71.44
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Total 199.00 8499.59 42.71
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Number of Children (Unduplicated) With at Least One Service 39
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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 151 126.75 4689.75 0.00
P 15 10.25 379.25 379.25
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 62.00 3430.59 0.00
Other 0 0.00 0.00 0.00
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Total 224 199.00 8499.59 379.25