CMS/EIP Fiscal Report Center: 06
Services beginning 10/01/2011 ending 12/31/2011 Date of Report:02/16/2012 Page: 1
List order: No List
Agency Filter:EIP DEI DEIP
Payclass Filters:TPIN
Eligibility Filter:Part C (excluding not eligible)
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) 47 48.000000 397.4400 8.2800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 45 46.000000 477.4800 10.3800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 46 47.000000 990.7600 21.0800
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.000000 54.3800 27.1900
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 5.000000 375.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 5.000000 375.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 79 124.000000 9300.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 64 99.500000 7462.5000 75.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 18 34.000000 2550.0000 75.0000
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 2 2.000000 114.5400 57.2700
Subtotal (Total Children Is Unduplicated) 96 412.500000 22097.1000 53.5687
-----------------------------------------------------------------------------------------------------------------------
Total 412.500000 22097.1000 53.5687
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 96
-----------------------------------------------------------------------------------------------------------------------
Center 06
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 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
315 412.500000 22097.1000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 315 412.500000 22097.1000 0.0000