CMS/EIP Fiscal Report Center: 03
Services beginning 10/01/2008 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 455 1134.75 41985.75 37.00
Subtotal (Total Children Is Unduplicated) 455 1134.75 41985.75 37.00
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Screening, Eval, and Assessment,Class #02
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 2 2.00 32.60 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 27 27.00 238.41 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 13 13.00 140.40 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 28 28.00 610.12 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.00 56.56 28.28
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 25 43.00 3225.00 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 24 40.50 2247.75 55.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 70 70.00 3500.00 50.00
Subtotal (Total Children Is Unduplicated) 103 227.50 10200.84 44.84
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Total 1362.25 52186.59 38.31
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Number of Children (Unduplicated) With at Least One Service 466
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Center 03
Flag Claims Units Chgs Paid
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R 11 5.50 203.50 0.00
U 0 0.00 0.00 0.00
B 540 451.50 19096.50 9.25
P 966 801.50 30576.75 30563.75
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
41 30.50 1185.50 0.00
Other 73 72.50 1096.59 18.50
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Total 1633 1362.25 52186.59 30600.75