CMS/EIP Fiscal Report Center: 03
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Payclass Filters:MED
Eligibility Filter:Program Patients
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 368 974.25 36047.25 37.00
Subtotal (Total Children Is Unduplicated) 368 974.25 36047.25 37.00
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 20 20.00 176.60 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 9 9.00 97.20 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 20 20.00 435.80 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 3.00 84.84 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.00 31.81 31.81
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.00 111.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 14 22.00 1650.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 16 26.50 1987.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 12 19.00 1054.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 18.00 1350.00 75.00
SCREEN-T1023-INTERDISCIPLINARY SCREENING 2 2.00 100.00 50.00
Subtotal (Total Children Is Unduplicated) 51 142.50 7079.25 49.68
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 3.50 175.00 50.00
Subtotal (Total Children Is Unduplicated) 2 3.50 175.00 50.00
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Total 1120.25 43301.50 38.65
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Number of Children (Unduplicated) With at Least One Service 373
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Center 03
Flag Claims Units Chgs Paid
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R 4 3.00 111.00 0.00
U 0 0.00 0.00 0.00
B 224 226.75 10882.75 0.00
P 1000 802.25 29759.25 29701.75
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
36 35.25 1722.25 0.00
Other 53 53.00 826.25 0.00
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Total 1317 1120.25 43301.50 29701.75