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
Payclass Filters:GR
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 500 268.00 9916.00 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 954 2582.75 95561.75 37.00
TCON-TCON-TRANSITION CONFERENCE 152 160.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1335 3961.75 119204.75 30.09
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 18 18.00 158.94 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 16 16.00 172.80 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 15 15.00 326.85 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.00 28.28 28.28
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 24 36.50 2737.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 20 31.50 2362.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 10.00 750.00 75.00
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 1 1.00 27.22 27.22
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 3 3.00 171.81 57.27
Subtotal (Total Children Is Unduplicated) 36 132.00 6735.90 51.03
----------------------------------------------------------------------------------------------------------------
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
----------------------------------------------------------------------------------------------------------------
Total 4155.75 126070.65 30.34
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1335
----------------------------------------------------------------------------------------------------------------
Center 06
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 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
6145 4155.75 126070.65 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 6145 4155.75 126070.65 0.00