CMS/EIP Fiscal Report Center: 06
Services beginning 10/01/2008 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 10 8.25 305.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 17 17.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 32 24.25 897.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 97 180.75 6687.75 37.00
Subtotal (Total Children Is Unduplicated) 98 230.25 7890.25 34.27
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 3 3.00 26.49 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 3 3.00 32.40 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 3 3.00 65.37 21.79
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.00 150.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.00 150.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 5.00 375.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 6.00 450.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 7.00 525.00 75.00
Subtotal (Total Children Is Unduplicated) 7 31.00 1774.26 57.23
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 12.00 600.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 13.00 882.44 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 3 582.00 291.00 0.50
Subtotal (Total Children Is Unduplicated) 3 607.00 1773.44 2.92
----------------------------------------------------------------------------------------------------------------
Total 868.25 11437.95 13.17
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 98
----------------------------------------------------------------------------------------------------------------
Center 06
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 238 137.50 5087.50 0.00
P 45 199.00 794.50 794.50
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
177 531.75 5555.95 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 460 868.25 11437.95 794.50