CMS/EIP Fiscal Report Center: 03
Services beginning 01/01/2010 ending 03/31/2010 Date of Report:05/17/2010 Page: 1
Agency Filter:EIP DEI DEIP
Payclass Filters:MED
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 568 1709.75 63260.75 37.00
Subtotal (Total Children Is Unduplicated) 568 1709.75 63260.75 37.00
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Screening, Eval, and Assessment,Class #02
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 2 2.00 32.60 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 32 32.00 282.56 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 12 12.00 129.60 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 30 30.00 653.70 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 2 2.00 108.76 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.00 28.28 28.28
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.00 150.00 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 3 6.00 333.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 39 63.00 4725.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 13.00 975.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 74 130.50 7242.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.00 150.00 75.00
SCREEN-T1023-INTERDISCIPLINARY SCREENING 13 27.00 1350.00 50.00
Subtotal (Total Children Is Unduplicated) 105 324.50 16311.25 50.27
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 13 60.50 3025.00 50.00
Subtotal (Total Children Is Unduplicated) 13 60.50 3025.00 50.00
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Total 2094.75 82597.00 39.43
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Number of Children (Unduplicated) With at Least One Service 569
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Center 03
Flag Claims Units Chgs Paid
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R 10 12.50 538.50 0.00
U 0 0.00 0.00 0.00
B 222 173.50 6561.25 64.75
P 2349 1753.50 70294.75 70113.50
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
51 76.25 3967.00 0.00
Other 79 79.00 1235.50 0.00
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Total 2711 2094.75 82597.00 70178.25