CMS/EIP Fiscal Report Center: 10
Services beginning 10/01/2011 ending 12/31/2011 Date of Report:02/15/2012 Page: 1
List order: No List
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 1 0.750000 27.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 128 133.750000 4948.7500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 259 1060.000000 39220.0000 37.0000
Subtotal (Total Children Is Unduplicated) 259 1194.500000 44196.5000 37.0000
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 3 3.000000 35.5800 11.8600
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 3 3.000000 24.8400 8.2800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 3 3.000000 31.1400 10.3800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 3 3.000000 63.2400 21.0800
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.000000 54.3800 27.1900
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 10 12.000000 900.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 7.000000 525.0000 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 14 25.500000 1415.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 89 156.000000 11700.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 58 80.500000 6037.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 30 42.500000 3187.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 147 256.000000 14208.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 35 40.000000 3000.0000 75.0000
Subtotal (Total Children Is Unduplicated) 184 635.500000 41332.4300 65.0392
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Total 1830.000000 85528.9300 46.7371
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Number of Children (Unduplicated) With at Least One Service 260
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Center 10
Flag Claims Units Chgs Paid
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R 4 3.000000 111.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 322 434.250000 26578.5000 1082.2500
P 774 696.500000 28090.4300 25549.0200
D 0 0.000000 0.0000 0.0000
S 8 11.250000 416.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
676 685.000000 30332.7500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1784 1830.000000 85528.9300 26631.2700