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:TPIN
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 1 0.50 18.50 37.00
Subtotal (Total Children Is Unduplicated) 1 0.50 18.50 37.00
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.00 10.62 10.62
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 3 3.00 48.90 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 33 33.00 291.39 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 14 14.00 151.20 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 31 31.00 675.49 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 3 3.00 163.14 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 6 6.00 169.68 28.28
Subtotal (Total Children Is Unduplicated) 36 91.00 1510.42 16.60
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Total 91.50 1528.92 16.71
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Number of Children (Unduplicated) With at Least One Service 37
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Center 03
Flag Claims Units Chgs Paid
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R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 0 0.00 0.00 0.00
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
1 0.50 18.50 0.00
Other 91 91.00 1510.42 0.00
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Total 92 91.50 1528.92 0.00