CMS/EIP Fiscal Report Center: 10
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 Page: 1
Payclass Filters:GR
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 149 566.25 20951.25 37.00
Subtotal (Total Children Is Unduplicated) 214 715.75 26482.75 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
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 23 40.50 3037.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 9 15.00 1125.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 12 20.50 1537.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 34 64.00 3552.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 19 21.00 1575.00 75.00
Subtotal (Total Children Is Unduplicated) 44 177.00 11087.39 62.64
----------------------------------------------------------------------------------------------------------------
Total 892.75 37570.14 42.08
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 223
----------------------------------------------------------------------------------------------------------------
Center 10
Flag Claims Units Chgs Paid
-------------------------------------------------
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 16 16.00 260.39 260.39
D 6 5.00 185.00 185.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
876 871.75 37124.75 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 898 892.75 37570.14 445.39