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: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 175 652.75 24151.75 37.00
Subtotal (Total Children Is Unduplicated) 175 652.75 24151.75 37.00
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 35 35.00 303.65 8.68
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 33 33.00 354.30 10.74
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 33 33.00 690.33 20.92
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 3.00 84.84 28.28
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.50 112.50 75.00
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 26 32.00 2400.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 20 24.00 1800.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 13 18.00 1350.00 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.50 112.50 75.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 5 5.00 286.35 57.27
Subtotal (Total Children Is Unduplicated) 54 187.50 7606.97 40.57
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Total 840.25 31758.72 37.80
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Number of Children (Unduplicated) With at Least One Service 175
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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 497 379.00 14023.00 0.00
P 330 253.25 9370.25 9370.25
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
204 208.00 8365.47 0.00
Other 0 0.00 0.00 0.00
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Total 1031 840.25 31758.72 9370.25