CMS/EIP Fiscal Report Center: 03
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Agency Filter:EIP DEI DEIP
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 382 998.75 36953.75 37.00
Subtotal (Total Children Is Unduplicated) 382 998.75 36953.75 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) 24 24.00 211.92 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 12 12.00 129.60 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 25 25.00 544.75 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.00 56.56 28.28
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 21 37.50 2812.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.00 150.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 19 33.50 1859.25 55.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 35 35.00 1750.00 50.00
Subtotal (Total Children Is Unduplicated) 63 172.00 7530.88 43.78
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Total 1170.75 44484.63 38.00
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Number of Children (Unduplicated) With at Least One Service 390
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Center 03
Flag Claims Units Chgs Paid
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R 6 3.50 129.50 0.00
U 0 0.00 0.00 0.00
B 454 369.50 15599.25 9.25
P 854 703.50 26620.50 26620.50
D 0 0.00 0.00 0.00
S 1 0.50 18.50 0.00
H 1 0.25 9.25 9.25
T 0 0.00 0.00 0.00
39 29.00 1130.00 0.00
Other 65 64.50 977.63 18.50
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Total 1420 1170.75 44484.63 26657.50