CMS/EIP Fiscal Report Center: 03
Services beginning 01/01/2010 ending 03/31/2010 Date of Report:05/17/2010 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 656 1943.75 71918.75 37.00
Subtotal (Total Children Is Unduplicated) 656 1943.75 71918.75 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) 35 35.00 309.05 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 12 12.00 129.60 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 33 33.00 719.07 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 2 2.00 108.76 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.00 28.28 28.28
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.00 150.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.00 225.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 7.00 388.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 50 80.50 6037.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 9 16.50 1237.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 92 160.00 8880.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.00 150.00 75.00
SCREEN-T1023-INTERDISCIPLINARY SCREENING 37 51.00 2550.00 50.00
Subtotal (Total Children Is Unduplicated) 146 407.00 20945.86 51.46
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 13 60.50 3025.00 50.00
Subtotal (Total Children Is Unduplicated) 13 60.50 3025.00 50.00
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Total 2411.25 95889.61 39.77
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Number of Children (Unduplicated) With at Least One Service 658
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Center 03
Flag Claims Units Chgs Paid
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R 11 13.25 566.25 0.00
U 0 0.00 0.00 0.00
B 243 206.25 7773.00 64.75
P 2608 2016.00 81522.75 81291.50
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
65 90.75 4700.25 0.00
Other 85 85.00 1327.36 0.00
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Total 3012 2411.25 95889.61 81356.25