CMS/EIP Fiscal Report Center: 03
Services beginning 10/01/2012 ending 12/31/2012 Date of Report:02/16/2013 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 124 256.000000 9472.0000 37.0000
Subtotal (Total Children Is Unduplicated) 124 256.000000 9472.0000 37.0000
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 7 7.000000 63.7700 9.1100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 3 3.000000 28.0200 9.3400
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 7 7.000000 152.1100 21.7300
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.000000 225.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 7.000000 388.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 9 13.500000 1012.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 31 49.500000 3712.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 3.000000 225.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 48 75.500000 4190.2500 55.5000
Subtotal (Total Children Is Unduplicated) 60 170.500000 10147.6500 59.5170
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Total 426.500000 19619.6500 46.0015
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Number of Children (Unduplicated) With at Least One Service 128
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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 77 86.500000 4393.7500 0.0000
P 372 320.000000 14757.0000 14763.7500
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
2 3.000000 225.0000 0.0000
Other 17 17.000000 243.9000 0.0000
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Total 468 426.500000 19619.6500 14763.7500