CMS/EIP Fiscal Report Center: 03
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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 59 23.75 878.75 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 9 10.25 379.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 181 479.25 17732.25 37.00
Subtotal (Total Children Is Unduplicated) 182 513.25 18990.25 37.00
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 2 2.00 17.66 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.00 10.80 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.00 43.58 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.00 54.38 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.00 28.28 28.28
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 2.50 187.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.00 150.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 4.50 249.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 22 32.00 2400.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 15 28.00 2100.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 49 82.50 4578.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.00 150.00 75.00
SCREEN-T1023-INTERDISCIPLINARY SCREENING 18 19.00 950.00 50.00
Subtotal (Total Children Is Unduplicated) 72 179.50 10920.70 60.84
----------------------------------------------------------------------------------------------------------------
Total 692.75 29910.95 43.18
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 183
----------------------------------------------------------------------------------------------------------------
Center 03
Flag Claims Units Chgs Paid
-------------------------------------------------
R 4 5.00 185.00 0.00
U 0 0.00 0.00 0.00
B 9 9.75 360.75 0.00
P 281 258.25 10082.75 10085.75
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 309 256.25 11696.25 11696.25
149 156.50 7431.50 0.00
Other 7 7.00 154.70 0.00
-------------------------------------------------
Total 759 692.75 29910.95 21782.00