CMS/EIP Fiscal Report Center: 06
Services beginning 10/01/2011 ending 12/31/2011 Date of Report:02/15/2012 Page: 1
List order: No List
Agency Filter:EIP DEI DEIP
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 884 2813.500000 104062.5000 36.9868
Subtotal (Total Children Is Unduplicated) 884 2813.500000 104062.5000 36.9868
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 46 46.000000 380.8800 8.2800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 46 46.000000 477.4800 10.3800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 46 46.000000 969.6800 21.0800
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.000000 54.3800 27.1900
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 7.500000 562.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 4.500000 337.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 112 171.000000 12825.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 100 154.000000 11550.0000 75.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 17 26.500000 1987.5000 75.0000
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 3 3.000000 171.8100 57.2700
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 2.000000 97.0000 48.5000
Subtotal (Total Children Is Unduplicated) 129 510.500000 29563.7300 57.9113
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Total 3324.000000 133626.2300 40.2004
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Number of Children (Unduplicated) With at Least One Service 884
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Center 06
Flag Claims Units Chgs Paid
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R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2681 1936.000000 71632.0000 0.0000
P 1263 872.250000 32236.2500 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
387 515.750000 29757.9800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 4331 3324.000000 133626.2300 0.0000