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: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 638 1825.25 67534.25 37.00
Subtotal (Total Children Is Unduplicated) 638 1825.25 67534.25 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) 26 26.00 229.58 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 13 13.00 140.40 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 25 25.00 544.75 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 29 43.50 3262.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 11 21.00 1575.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 69 118.50 6576.75 55.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 6 6.00 300.00 50.00
Subtotal (Total Children Is Unduplicated) 98 267.00 13229.29 49.55
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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
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Total 2117.25 82013.54 38.74
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Number of Children (Unduplicated) With at Least One Service 638
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Center 03
Flag Claims Units Chgs Paid
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R 51 46.00 1907.50 0.00
U 0 0.00 0.00 0.00
B 71 56.50 2185.00 0.00
P 2507 1837.00 72838.00 72813.25
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
122 105.75 3949.75 0.00
Other 72 72.00 1133.29 0.00
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Total 2823 2117.25 82013.54 72813.25