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:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 645 1008.750000 37323.7500 37.0000
Subtotal (Total Children Is Unduplicated) 645 1008.750000 37323.7500 37.0000
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 26 26.000000 236.8600 9.1100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 10 10.000000 93.4000 9.3400
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 27 27.000000 586.7100 21.7300
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 24.4700 24.4700
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.000000 166.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 11 18.000000 1350.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 17 31.000000 2325.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 42 76.000000 4218.0000 55.5000
Subtotal (Total Children Is Unduplicated) 66 197.000000 9375.9400 47.5936
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 14 72.250000 3612.5000 50.0000
Subtotal (Total Children Is Unduplicated) 14 72.250000 3612.5000 50.0000
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Total 1278.000000 50312.1900 39.3679
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Number of Children (Unduplicated) With at Least One Service 653
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Center 03
Flag Claims Units Chgs Paid
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R 12 7.500000 277.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 313 227.250000 9754.2500 0.0000
P 1788 977.750000 39226.5000 39255.7500
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
1 1.500000 112.5000 0.0000
Other 64 64.000000 941.4400 0.0000
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Total 2178 1278.000000 50312.1900 39255.7500