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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 769 1264.750000 46795.7500 37.0000
Subtotal (Total Children Is Unduplicated) 769 1264.750000 46795.7500 37.0000
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 33 33.000000 300.6300 9.1100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 13 13.000000 121.4200 9.3400
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 34 34.000000 738.8200 21.7300
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 24.4700 24.4700
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 3 5.000000 375.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 10.000000 555.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 20 31.500000 2362.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 48 80.500000 6037.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 5.000000 375.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 90 151.500000 8408.2500 55.5000
Subtotal (Total Children Is Unduplicated) 126 367.500000 19523.5900 53.1254
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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 1704.500000 69931.8400 41.0278
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Number of Children (Unduplicated) With at Least One Service 781
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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 390 313.750000 14148.0000 0.0000
P 2160 1297.750000 53983.5000 54019.5000
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
3 4.500000 337.5000 0.0000
Other 81 81.000000 1185.3400 0.0000
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Total 2646 1704.500000 69931.8400 54019.5000