CMS/EIP Fiscal Report Center: 03
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 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 107 210.50 7788.50 37.00
Subtotal (Total Children Is Unduplicated) 107 210.50 7788.50 37.00
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Screening, Eval, and Assessment,Class #02
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.00 16.30 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 4 4.00 35.32 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.00 21.60 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 3 3.00 65.37 21.79
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 7 12.50 937.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 4.00 300.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 7 12.50 693.75 55.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 39 39.00 1950.00 50.00
Subtotal (Total Children Is Unduplicated) 46 78.00 4019.84 51.54
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Total 288.50 11808.34 40.93
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Number of Children (Unduplicated) With at Least One Service 107
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Center 03
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 7 4.50 166.50 0.00
P 277 240.00 10245.25 10245.25
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
40 34.00 1258.00 0.00
Other 10 10.00 138.59 0.00
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Total 334 288.50 11808.34 10245.25