CMS/EIP Fiscal Report Center: 03
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 Page: 1
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
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 542 1558.50 57664.50 37.00
Subtotal (Total Children Is Unduplicated) 542 1558.50 57664.50 37.00
----------------------------------------------------------------------------------------------------------------
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) 25 25.00 220.75 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 13 13.00 140.40 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 24 24.00 522.96 21.79
AUDE-92586-AUD EVOKED RESPONSE (SCREEN) 2 2.00 60.86 30.43
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 5 5.00 141.40 28.28
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 2.50 187.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 3.50 194.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 26 40.00 3000.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 10 19.00 1425.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 62 107.50 5966.25 55.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 3 3.00 150.00 50.00
Subtotal (Total Children Is Unduplicated) 87 245.50 12025.67 48.98
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4 25.00 1250.00 50.00
Subtotal (Total Children Is Unduplicated) 4 25.00 1250.00 50.00
----------------------------------------------------------------------------------------------------------------
Total 1829.00 70940.17 38.79
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 542
----------------------------------------------------------------------------------------------------------------
Center 03
Flag Claims Units Chgs Paid
-------------------------------------------------
R 47 41.00 1722.50 0.00
U 0 0.00 0.00 0.00
B 62 46.75 1824.25 0.00
P 2227 1580.75 62905.25 62877.50
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
107 90.50 3385.50 0.00
Other 70 70.00 1102.67 0.00
-------------------------------------------------
Total 2513 1829.00 70940.17 62877.50