CMS/EIP Fiscal Report Center: 03
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Agency Filter:EIP DEI DEIP
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 328 865.75 32032.75 37.00
Subtotal (Total Children Is Unduplicated) 328 865.75 32032.75 37.00
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 17 17.00 150.11 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 8 8.00 86.40 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 17 17.00 370.43 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 3.00 84.84 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.00 31.81 31.81
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.00 111.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 10 17.00 1275.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 13 22.50 1687.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 7 12.50 693.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 14.00 1050.00 75.00
SCREEN-T1023-INTERDISCIPLINARY SCREENING 2 2.00 100.00 50.00
Subtotal (Total Children Is Unduplicated) 40 116.00 5640.84 48.63
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 3.50 175.00 50.00
Subtotal (Total Children Is Unduplicated) 2 3.50 175.00 50.00
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Total 985.25 37848.59 38.42
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Number of Children (Unduplicated) With at Least One Service 331
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Center 03
Flag Claims Units Chgs Paid
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R 4 3.00 111.00 0.00
U 0 0.00 0.00 0.00
B 203 200.25 9421.00 0.00
P 894 708.75 26299.75 26242.25
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
28 27.25 1293.25 0.00
Other 46 46.00 723.59 0.00
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Total 1175 985.25 37848.59 26242.25