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: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 1000 4962.75 183621.75 37.00
Subtotal (Total Children Is Unduplicated) 1000 4962.75 183621.75 37.00
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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 4 4.00 65.20 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 80 84.00 726.42 8.65
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 47 53.00 567.36 10.70
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 81 86.00 1797.30 20.90
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 6 9.50 712.50 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 5 8.50 471.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 37 61.00 4575.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 47 77.50 5812.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 16 25.50 1912.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 61 98.50 5466.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 33 52.50 3937.50 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 73 73.00 3650.00 50.00
Subtotal (Total Children Is Unduplicated) 247 664.00 31136.57 46.89
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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
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Total 5752.00 221445.47 38.50
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Number of Children (Unduplicated) With at Least One Service 1012
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Center 03
Flag Claims Units Chgs Paid
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R 21 14.25 527.25 0.00
U 0 0.00 0.00 0.00
B 808 718.75 31694.01 83.25
P 6088 4719.25 183282.31 183038.81
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
56 46.50 1777.50 0.00
Other 253 252.00 4118.15 18.50
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Total 7229 5752.00 221445.47 183149.81