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
Payclass Filters:GR
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 100 380.500000 14078.5000 37.0000
Subtotal (Total Children Is Unduplicated) 175 515.000000 19055.0000 37.0000
-----------------------------------------------------------------------------------------------------------------------
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
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 8 15.000000 1125.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 6.500000 487.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 11.000000 825.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 16 28.000000 1554.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 3.500000 262.5000 75.0000
Subtotal (Total Children Is Unduplicated) 22 78.000000 4463.1800 57.2203
-----------------------------------------------------------------------------------------------------------------------
Total 593.000000 23518.1800 39.6597
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 177
-----------------------------------------------------------------------------------------------------------------------
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 14 14.000000 209.1800 209.1800
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
613 579.000000 23309.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 627 593.000000 23518.1800 209.1800