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
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 1164 846.75 31329.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 1730 2525.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1415 1637.50 60586.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1710 10476.3 387528.50 36.99
TCON-TCON-TRANSITION CONFERENCE 651 692.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 2491 16177.5 479444.75 29.64
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 91 94.00 815.62 8.68
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 82 85.00 912.12 10.73
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 80 83.00 1741.51 20.98
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 7 7.00 196.87 28.12
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 125 196.50 14737.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 134 218.00 16350.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 41 69.00 5175.00 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 18.00 1350.00 75.00
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 2 2.00 54.44 27.22
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 10 10.00 587.02 58.70
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 3 3.00 103.50 34.50
Subtotal (Total Children Is Unduplicated) 271 794.50 42698.58 53.74
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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 1 1.50 101.82 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) 7 328.50 867.92 2.64
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Total 17300.50 523011.25 30.23
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Number of Children (Unduplicated) With at Least One Service 2492
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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 0 0.00 0.00 0.00
P 1817 1206.75 36175.66 36175.66
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
22404 16093.75 486835.59 3922.00
Other 0 0.00 0.00 0.00
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Total 24221 17300.50 523011.25 40097.66