CMS/EIP Fiscal Report Center: 06
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 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 1165 848.75 31403.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 1737 2534.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1422 1643.75 60817.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 2699 17226.0 637247.50 36.99
TCON-TCON-TRANSITION CONFERENCE 651 692.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 2701 22944.5 729469.00 31.79
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 905 945.00 8185.95 8.66
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 819 856.00 9179.28 10.72
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 806 843.00 17626.52 20.91
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 86 86.00 2417.91 28.12
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 19 31.00 2325.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 24 39.50 2962.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 11 20.00 1500.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.50 112.50 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 701 1099.50 82462.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 598 939.00 70425.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 305 486.00 36450.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 4.00 222.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 37 62.50 4687.50 75.00
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 31 31.00 857.40 27.66
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 109 109.00 6557.47 60.16
MED-99212-OUTPATIENT VISIT, EST, 10 MINS 4 4.00 72.68 18.17
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 13 13.00 457.11 35.16
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 2 2.00 97.00 48.50
Subtotal (Total Children Is Unduplicated) 1196 5574.00 246695.32 44.26
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 2.00 100.00 50.00
INTR-INTR-INTERPRETER 4 8.00 487.00 60.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 5.00 339.40 67.88
TRAN-TRAN-FAMILY TRANSPORTATION 2 2.00 21.60 10.80
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 4 315.00 157.50 0.50
Subtotal (Total Children Is Unduplicated) 7 332.00 1105.50 3.33
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Total 28850.50 977269.82 33.87
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Number of Children (Unduplicated) With at Least One Service 2703
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Center 06
Flag Claims Units Chgs Paid
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R 2 1.50 55.50 0.00
U 0 0.00 0.00 0.00
B 6094 3983.75 147377.00 1535.50
P 5570 3652.50 126668.41 126668.41
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
26909 21212.75 703168.91 3931.25
Other 0 0.00 0.00 0.00
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Total 38575 28850.50 977269.82 132135.16