CMS/EIP Fiscal Report Center: 03
Services beginning 10/01/2011 ending 12/31/2011 Date of Report:02/15/2012 Page: 1
List order: No List
Agency Filter:EIP DEI DEIP
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 726 2012.250000 74453.2500 37.0000
Subtotal (Total Children Is Unduplicated) 726 2012.250000 74453.2500 37.0000
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 30 30.000000 248.4000 8.2800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 5 5.000000 51.9000 10.3800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 30 30.000000 632.4000 21.0800
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 2 2.000000 103.5200 51.7600
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 3.000000 81.5700 27.1900
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 5.000000 277.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 25 42.000000 3150.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 24 41.000000 3075.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 21 34.500000 2587.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 48 76.500000 4245.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
SCREEN-T1023-INTERDISCIPLINARY SCREENING 12 12.000000 600.0000 50.0000
Subtotal (Total Children Is Unduplicated) 111 287.500000 15541.0400 54.0558
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 14.750000 737.5000 50.0000
Subtotal (Total Children Is Unduplicated) 3 14.750000 737.5000 50.0000
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Total 2314.500000 90731.7900 39.2015
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Number of Children (Unduplicated) With at Least One Service 732
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Center 03
Flag Claims Units Chgs Paid
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R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 51 26.000000 1046.7500 0.0000
P 3625 2215.250000 88447.0000 88437.7500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 74 73.250000 1238.0400 0.0000
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Total 3750 2314.500000 90731.7900 88437.7500