CMS/EIP Fiscal Report Center: 03
Services beginning 10/01/2011 ending 12/31/2011 Date of Report:02/16/2012 Page: 1
List order: No List
Payclass Filters:MED
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 795 2210.250000 81779.2500 37.0000
Subtotal (Total Children Is Unduplicated) 795 2210.250000 81779.2500 37.0000
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 33 33.000000 273.2400 8.2800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 6 6.000000 62.2800 10.3800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 33 33.000000 695.6400 21.0800
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 2 2.000000 103.5200 51.7600
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 3.000000 81.5700 27.1900
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 4.500000 337.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 5.000000 277.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 38 61.000000 4575.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 40 66.500000 4987.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 28 45.000000 3375.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 66 102.500000 5688.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
SCREEN-T1023-INTERDISCIPLINARY SCREENING 13 13.000000 650.0000 50.0000
Subtotal (Total Children Is Unduplicated) 148 378.000000 21370.0000 56.5344
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 14.750000 737.5000 50.0000
Subtotal (Total Children Is Unduplicated) 3 14.750000 737.5000 50.0000
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Total 2603.000000 103886.7500 39.9104
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Number of Children (Unduplicated) With at Least One Service 802
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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 60 32.500000 1458.2500 0.0000
P 3953 2490.250000 101092.0000 101085.7500
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 81 80.250000 1336.5000 0.0000
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Total 4094 2603.000000 103886.7500 101085.7500