CMS/EIP Fiscal Report Center: 06
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Eligibility Filter:DEI Only
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 20 9.00 333.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 18 22.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 33 34.00 1258.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 104 181.50 6715.50 37.00
Subtotal (Total Children Is Unduplicated) 105 246.50 8306.50 33.70
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 2 2.00 17.66 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.00 21.60 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.00 21.79 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.00 56.56 28.28
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.00 75.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.00 75.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 2.50 187.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 5.50 412.50 75.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 2 2.00 114.54 57.27
Subtotal (Total Children Is Unduplicated) 5 19.00 982.15 51.69
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EI Services,Class #03
INTR-INTR-INTERPRETER 1 2.00 117.00 58.50
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 1.00 67.88 67.88
TRAN-TRAN-FAMILY TRANSPORTATION 1 1.00 10.80 10.80
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 2 135.00 67.50 0.50
Subtotal (Total Children Is Unduplicated) 2 139.00 263.18 1.89
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Total 404.50 9551.83 23.61
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Number of Children (Unduplicated) With at Least One Service 105
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Center 06
Flag Claims Units Chgs Paid
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R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 239 130.75 4837.75 0.00
P 2 90.00 45.00 45.00
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
196 183.75 4669.08 0.00
Other 0 0.00 0.00 0.00
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Total 437 404.50 9551.83 45.00