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:Not Part C
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 16 8.00 296.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 2 2.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 61 54.00 1998.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 130 409.50 15142.25 36.98
Subtotal (Total Children Is Unduplicated) 130 473.50 17436.25 36.82
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 25 25.00 220.75 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 26 26.00 280.80 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 27 27.00 588.33 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.00 56.56 28.28
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 2.50 187.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 25 27.00 2025.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 23 26.50 1987.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 13 17.00 1275.00 75.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 3 3.00 171.81 57.27
Subtotal (Total Children Is Unduplicated) 40 157.00 6868.25 43.75
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EI Services,Class #03
INTR-INTR-INTERPRETER 2 4.00 234.00 58.50
TRAN-TRAN-FAMILY TRANSPORTATION 2 2.00 21.60 10.80
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 2 90.00 45.00 0.50
Subtotal (Total Children Is Unduplicated) 2 96.00 300.60 3.13
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Total 726.50 24605.10 33.87
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Number of Children (Unduplicated) With at Least One Service 130
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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 165 129.00 4773.00 0.00
P 3 48.00 150.30 150.30
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
613 549.50 19681.80 0.00
Other 0 0.00 0.00 0.00
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Total 781 726.50 24605.10 150.30