CMS/EIP Fiscal Report Center: 06
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/16/2009 Page: 1
Payclass Filters:MED
Eligibility Filter:DEI Only
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 121 532.00 19684.00 37.00
Subtotal (Total Children Is Unduplicated) 121 532.00 19684.00 37.00
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 11 11.00 91.73 8.34
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 11 11.00 116.28 10.57
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 10 10.00 189.16 18.92
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.00 56.56 28.28
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.50 112.50 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 7.50 562.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 6.00 450.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 12.50 937.50 75.00
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 1 1.00 34.01 34.01
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 3 3.00 186.13 62.04
Subtotal (Total Children Is Unduplicated) 17 65.50 2736.37 41.78
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 1.00 50.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 13.00 882.44 67.88
Subtotal (Total Children Is Unduplicated) 3 14.00 932.44 66.60
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Total 611.50 23352.81 38.19
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Number of Children (Unduplicated) With at Least One Service 121
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Center 06
Flag Claims Units Chgs Paid
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R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 636 361.25 13366.25 55.50
P 297 164.75 6095.75 6095.75
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
83 85.50 3890.81 0.00
Other 0 0.00 0.00 0.00
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Total 1016 611.50 23352.81 6151.25