CMS/EIP Fiscal Report Center: 03
Services beginning 10/01/2011 ending 12/31/2011 Date of Report:02/15/2012 Page: 1
List order: No List
Payclass Filters:MED
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 69 198.000000 7326.0000 37.0000
Subtotal (Total Children Is Unduplicated) 69 198.000000 7326.0000 37.0000
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 3 3.000000 24.8400 8.2800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 10.3800 10.3800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 3 3.000000 63.2400 21.0800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 13 19.000000 1425.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 16 25.500000 1912.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 10.500000 787.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 18 26.000000 1443.0000 55.5000
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 1.000000 50.0000 50.0000
Subtotal (Total Children Is Unduplicated) 37 90.500000 5828.9600 64.4084
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Total 288.500000 13154.9600 45.5978
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Number of Children (Unduplicated) With at Least One Service 70
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Center 03
Flag Claims Units Chgs Paid
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R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 9 6.500000 411.5000 0.0000
P 328 275.000000 12645.0000 12648.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 7 7.000000 98.4600 0.0000
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Total 344 288.500000 13154.9600 12648.0000