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: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 598 1690.25 62539.25 37.00
Subtotal (Total Children Is Unduplicated) 598 1690.25 62539.25 37.00
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Screening, Eval, and Assessment,Class #02
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 2 2.00 32.60 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 38 38.00 335.54 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 11 11.00 118.80 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 38 38.00 828.02 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.00 28.28 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 1.50 112.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.50 83.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 31 51.00 3825.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 16 26.50 1987.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 45 76.50 4245.75 55.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 62 62.00 3100.00 50.00
Subtotal (Total Children Is Unduplicated) 129 310.00 14729.05 47.51
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 9 39.50 1975.00 50.00
Subtotal (Total Children Is Unduplicated) 9 39.50 1975.00 50.00
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Total 2039.75 79243.30 38.85
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Number of Children (Unduplicated) With at Least One Service 605
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Center 03
Flag Claims Units Chgs Paid
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R 3 0.75 27.75 0.00
U 0 0.00 0.00 0.00
B 77 47.00 1792.75 0.00
P 2196 1650.75 66788.50 73923.00
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
338 246.25 9111.25 0.00
Other 94 95.00 1523.05 27.75
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Total 2708 2039.75 79243.30 73950.75