CMS/EIP Fiscal Report Center: 06
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Agency Filter:EIP DEI DEIP
Eligibility Filter:Part C (excluding not eligible)
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 500 268.75 9943.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 546 580.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 432 371.00 13727.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1576 4350.50 160968.50 37.00
TCON-TCON-TRANSITION CONFERENCE 152 160.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1586 5730.25 184639.25 32.22
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 201 201.00 1774.83 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 187 187.00 2019.60 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 181 181.00 3943.99 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 21 21.00 593.88 28.28
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.50 112.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.50 112.50 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 202 305.50 22912.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 117 172.50 12937.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 95 148.50 11137.50 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 10.50 787.50 75.00
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 9 9.00 244.98 27.22
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 30 30.00 1718.10 57.27
MED-99212-OUTPATIENT VISIT, EST, 10 MINS 1 1.00 18.17 18.17
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 2 2.00 69.00 34.50
Subtotal (Total Children Is Unduplicated) 271 1272.00 58382.55 45.90
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 2.00 100.00 50.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 60.00 30.00 0.50
Subtotal (Total Children Is Unduplicated) 1 62.00 130.00 2.10
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Total 7064.25 243151.80 34.42
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Number of Children (Unduplicated) With at Least One Service 1586
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Center 06
Flag Claims Units Chgs Paid
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R 1 0.50 18.50 0.00
U 0 0.00 0.00 0.00
B 2568 1680.75 62187.75 0.00
P 0 0.00 0.00 0.00
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
7236 5383.00 180945.55 0.00
Other 0 0.00 0.00 0.00
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Total 9805 7064.25 243151.80 0.00