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: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) 56 56.00 494.48 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 57 57.00 615.60 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 53 53.00 1154.87 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.00 28.28 28.28
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.50 262.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 5.50 412.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.00 300.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 70 95.50 7162.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 76 116.00 8700.00 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 17.00 1275.00 75.00
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 4 4.00 108.88 27.22
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 11 11.00 629.97 57.27
Subtotal (Total Children Is Unduplicated) 124 423.50 21144.58 49.93
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Total 423.50 21144.58 49.93
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Number of Children (Unduplicated) With at Least One Service 124
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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
347 423.50 21144.58 0.00
Other 0 0.00 0.00 0.00
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Total 347 423.50 21144.58 0.00