CMS/EIP Fiscal Report Center: 03
Services beginning 10/01/2008 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 73 136.00 5032.00 37.00
Subtotal (Total Children Is Unduplicated) 73 136.00 5032.00 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) 3 3.00 26.49 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.00 10.80 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 3 3.00 65.37 21.79
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 5.50 412.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 5 7.00 388.50 55.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 35 35.00 1750.00 50.00
Subtotal (Total Children Is Unduplicated) 40 55.50 2669.96 48.11
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Total 191.50 7701.96 40.22
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Number of Children (Unduplicated) With at Least One Service 76
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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 86 82.00 3497.25 0.00
P 112 98.00 3956.25 3943.25
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
2 1.50 55.50 0.00
Other 8 8.00 118.96 0.00
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Total 213 191.50 7701.96 3943.25