CMS/EIP Fiscal Report Center: 03
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
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 807 4307.50 159377.50 37.00
Subtotal (Total Children Is Unduplicated) 807 4307.50 159377.50 37.00
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 2.00 22.87 11.44
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 3 3.00 48.90 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 72 76.00 655.78 8.63
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 44 50.00 534.96 10.70
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 73 78.00 1622.98 20.81
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 4 4.00 206.20 51.55
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 12 12.00 333.91 27.83
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.00 31.81 31.81
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.50 112.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 8.00 600.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.00 150.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 6.50 487.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 7.00 388.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 28 49.00 3675.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 31 54.00 4050.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 14 23.00 1725.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 46 77.00 4273.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 21 34.50 2587.50 75.00
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 37 37.00 1850.00 50.00
Subtotal (Total Children Is Unduplicated) 179 527.50 23453.91 44.46
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 11 101.50 5075.00 50.00
PHY-97110-PT SESSION BY LICENSED PT 3 23.75 1612.15 67.88
Subtotal (Total Children Is Unduplicated) 13 125.25 6687.15 53.39
----------------------------------------------------------------------------------------------------------------
Total 4960.25 189518.56 38.21
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 815
----------------------------------------------------------------------------------------------------------------
Center 03
Flag Claims Units Chgs Paid
-------------------------------------------------
R 16 12.25 453.25 0.00
U 0 0.00 0.00 0.00
B 685 596.50 26017.26 83.25
P 5292 4074.25 157492.31 157289.56
D 0 0.00 0.00 0.00
S 2 1.00 37.00 0.00
H 1 0.25 9.25 9.25
T 0 0.00 0.00 0.00
53 44.00 1685.00 0.00
Other 233 232.00 3824.49 18.50
-------------------------------------------------
Total 6282 4960.25 189518.56 157400.56