CMS/EIP Fiscal Report Center: 03
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/16/2009 Page: 1
Payclass Filters:MED
Eligibility Filter:Not Part C
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 190 652.00 24124.00 37.00
Subtotal (Total Children Is Unduplicated) 190 652.00 24124.00 37.00
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Screening, Eval, and Assessment,Class #02
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.00 16.30 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 8 8.00 70.64 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 3 3.00 32.40 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 8 8.00 174.32 21.79
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.50 112.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.50 83.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 9 12.00 900.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 16 23.50 1762.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 2.50 187.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 15 21.50 1193.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 18.00 1350.00 75.00
SCREEN-T1023-INTERDISCIPLINARY SCREENING 36 36.00 1800.00 50.00
Subtotal (Total Children Is Unduplicated) 68 136.50 7682.66 56.28
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Total 788.50 31806.66 40.34
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Number of Children (Unduplicated) With at Least One Service 194
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Center 03
Flag Claims Units Chgs Paid
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R 5 2.00 74.00 0.00
U 0 0.00 0.00 0.00
B 123 122.25 5676.75 0.00
P 788 641.75 25669.75 25629.00
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
3 2.50 92.50 0.00
Other 20 20.00 293.66 0.00
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Total 939 788.50 31806.66 25629.00