CMS/EIP Fiscal Report Center: 06
Services beginning 10/01/2008 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 75 143.50 5309.50 37.00
Subtotal (Total Children Is Unduplicated) 75 143.50 5309.50 37.00
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 3 3.00 26.49 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 3 3.00 32.40 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 3 3.00 65.37 21.79
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 5.00 375.00 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 4 7.00 525.00 75.00
Subtotal (Total Children Is Unduplicated) 6 27.00 1474.26 54.60
----------------------------------------------------------------------------------------------------------------
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
----------------------------------------------------------------------------------------------------------------
Total 184.50 7716.20 41.82
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 75
----------------------------------------------------------------------------------------------------------------
Center 06
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 238 137.50 5087.50 0.00
P 0 0.00 0.00 0.00
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
46 47.00 2628.70 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 284 184.50 7716.20 0.00