CMS/EIP Fiscal Report Center: 06
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 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 38 24.75 915.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 67 74.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 100 128.25 4745.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 167 677.50 25067.50 37.00
Subtotal (Total Children Is Unduplicated) 168 904.50 30728.50 33.97
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 13 13.00 109.39 8.41
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 12 12.00 127.08 10.59
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 11 11.00 210.95 19.18
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 3.00 84.84 28.28
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.00 225.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 4.50 337.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.50 112.50 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 7 9.50 712.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 9.00 675.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 12 18.00 1350.00 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.00 225.00 75.00
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 1 1.00 34.01 34.01
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 3 3.00 186.13 62.04
Subtotal (Total Children Is Unduplicated) 21 91.50 4389.90 47.98
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 14.00 700.00 50.00
INTR-INTR-INTERPRETER 1 2.00 117.00 58.50
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 14.00 950.32 67.88
TRAN-TRAN-FAMILY TRANSPORTATION 2 2.00 54.80 27.40
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 5 747.00 373.50 0.50
Subtotal (Total Children Is Unduplicated) 6 779.00 2195.62 2.82
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Total 1775.00 37314.02 21.02
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Number of Children (Unduplicated) With at Least One Service 168
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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 636 361.25 13366.25 55.50
P 349 486.75 7094.25 7094.25
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
668 927.00 16853.52 101.75
Other 0 0.00 0.00 0.00
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Total 1653 1775.00 37314.02 7251.50