CMS/EIP Fiscal Report Center: 03
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 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 550 1472.00 54464.00 37.00
Subtotal (Total Children Is Unduplicated) 550 1472.00 54464.00 37.00
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Screening, Eval, and Assessment,Class #02
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 3 3.00 48.90 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 39 39.00 344.37 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 14 14.00 151.20 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 36 36.00 784.44 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 3.00 84.84 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.00 31.81 31.81
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.00 150.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.00 111.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 25 42.00 3150.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 13 21.50 1612.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 27 43.50 2414.25 55.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 56 56.00 2800.00 50.00
Subtotal (Total Children Is Unduplicated) 115 263.00 11683.31 44.42
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4 24.00 1200.00 50.00
Subtotal (Total Children Is Unduplicated) 4 24.00 1200.00 50.00
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Total 1759.00 67347.31 38.29
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Number of Children (Unduplicated) With at Least One Service 554
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Center 03
Flag Claims Units Chgs Paid
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R 4 2.50 120.25 0.00
U 0 0.00 0.00 0.00
B 660 469.25 18830.25 37.00
P 1339 1031.00 40357.00 40357.00
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
195 157.00 6474.00 0.00
Other 98 99.25 1565.81 0.00
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Total 2296 1759.00 67347.31 40394.00