CMS/EIP Fiscal Report Center: 10
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 5 2.25 83.25 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 159 159.25 5892.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 352 1304.00 48248.00 37.00
Subtotal (Total Children Is Unduplicated) 354 1465.50 54223.50 37.00
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 5 5.00 53.10 10.62
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 5 5.00 44.15 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 5 5.00 51.90 10.38
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 5 5.00 108.95 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 3.00 84.84 28.28
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 9 16.50 1237.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 8 13.50 1012.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.00 150.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 2.50 187.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 9 15.50 860.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 93 150.50 11287.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 88 133.50 10012.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 56 91.00 6825.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 180 312.50 17343.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 78 87.00 6525.00 75.00
Subtotal (Total Children Is Unduplicated) 251 847.50 55784.44 65.82
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Total 2313.00 110007.94 47.56
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Number of Children (Unduplicated) With at Least One Service 355
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Center 10
Flag Claims Units Chgs Paid
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R 74 77.00 3747.75 0.00
U 0 0.00 0.00 0.00
B 789 721.25 30690.75 0.00
P 222 307.50 18014.19 18014.19
D 0 0.00 0.00 0.00
S 7 4.25 157.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
1139 1203.00 57398.00 0.00
Other 0 0.00 0.00 0.00
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Total 2231 2313.00 110007.94 18014.19