CMS/EIP Fiscal Report Center: 06
Services beginning 04/01/2010 ending 06/30/2010 Date of Report:08/18/2010 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 841 2917.25 107938.25 37.00
Subtotal (Total Children Is Unduplicated) 841 2917.25 107938.25 37.00
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 45 45.00 397.35 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 45 45.00 486.00 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 42 42.00 915.18 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.00 28.28 28.28
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.50 112.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 5.00 375.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 70 97.50 7312.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 95 143.00 10725.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.50 83.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 16 23.50 1762.50 75.00
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 2 2.00 54.44 27.22
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 9 9.00 515.43 57.27
Subtotal (Total Children Is Unduplicated) 127 416.00 22767.43 54.73
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Total 3333.25 130705.68 39.21
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Number of Children (Unduplicated) With at Least One Service 841
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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 3832 2513.25 92990.25 18.50
P 451 291.25 10776.25 10776.25
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
543 528.75 26939.18 0.00
Other 0 0.00 0.00 0.00
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Total 4826 3333.25 130705.68 10794.75