CMS/EIP Fiscal Report Center: 10
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 Page: 1
Eligibility Filter:Not Part C
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 2 1.00 37.00 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 151 148.50 5494.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 294 1056.50 39090.50 37.00
Subtotal (Total Children Is Unduplicated) 294 1206.00 44622.00 37.00
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 3 3.00 31.86 10.62
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 3 3.00 26.49 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 3 3.00 31.14 10.38
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 4 4.00 86.06 21.52
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 3.00 84.84 28.28
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 2.50 187.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.50 262.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.00 150.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 5.00 277.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 112 190.00 14250.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 51 83.00 6225.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 57 89.00 6675.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 141 261.00 14485.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 73 90.00 6750.00 75.00
Subtotal (Total Children Is Unduplicated) 188 742.00 49523.39 66.74
----------------------------------------------------------------------------------------------------------------
Total 1948.00 94145.39 48.33
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 294
----------------------------------------------------------------------------------------------------------------
Center 10
Flag Claims Units Chgs Paid
-------------------------------------------------
R 1 0.25 9.25 0.00
U 0 0.00 0.00 0.00
B 500 461.75 20012.75 0.00
P 185 255.50 14876.64 14876.64
D 6 5.00 185.00 185.00
S 66 66.25 2451.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
1046 1159.25 56610.50 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 1804 1948.00 94145.39 15061.64