CMS/EIP Fiscal Report Center: 03
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 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 455 1257.50 46527.50 37.00
Subtotal (Total Children Is Unduplicated) 455 1257.50 46527.50 37.00
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 3 3.00 48.90 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 32 32.00 282.56 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 11 11.00 118.80 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 29 29.00 631.91 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.00 56.56 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.00 31.81 31.81
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 17 30.50 2287.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 10 18.50 1387.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 19 33.00 1831.50 55.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 28 28.00 1400.00 50.00
Subtotal (Total Children Is Unduplicated) 76 188.00 8077.04 42.96
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4 24.00 1200.00 50.00
Subtotal (Total Children Is Unduplicated) 4 24.00 1200.00 50.00
----------------------------------------------------------------------------------------------------------------
Total 1469.50 55804.54 37.98
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 459
----------------------------------------------------------------------------------------------------------------
Center 03
Flag Claims Units Chgs Paid
-------------------------------------------------
R 4 2.50 120.25 0.00
U 0 0.00 0.00 0.00
B 565 388.25 15142.25 0.00
P 1154 867.75 33785.50 33785.50
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
168 132.50 5567.50 0.00
Other 79 78.50 1189.04 0.00
-------------------------------------------------
Total 1970 1469.50 55804.54 33785.50