CMS/EIP Fiscal Report Center: 03
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 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 491 1479.75 54750.75 37.00
Subtotal (Total Children Is Unduplicated) 491 1479.75 54750.75 37.00
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Screening, Eval, and Assessment,Class #02
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.00 16.30 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 34 34.00 300.22 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 9 9.00 97.20 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 35 35.00 762.65 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.00 28.28 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.00 31.81 31.81
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.50 112.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.50 83.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 24 38.50 2887.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 14 22.50 1687.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 38 64.00 3552.00 55.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 23 23.00 1150.00 50.00
Subtotal (Total Children Is Unduplicated) 83 232.00 10709.21 46.16
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 9 39.50 1975.00 50.00
Subtotal (Total Children Is Unduplicated) 9 39.50 1975.00 50.00
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Total 1751.25 67434.96 38.51
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Number of Children (Unduplicated) With at Least One Service 498
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Center 03
Flag Claims Units Chgs Paid
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R 3 0.75 27.75 0.00
U 0 0.00 0.00 0.00
B 70 42.50 1626.25 0.00
P 1919 1410.75 56543.25 63677.75
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
298 212.25 7853.25 0.00
Other 84 85.00 1384.46 27.75
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Total 2374 1751.25 67434.96 63705.50