CMS/EIP Fiscal Report Center: 06
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 Page: 1
Eligibility Filter:Not Part C
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 35 17.75 656.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 4 4.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 37 36.75 1359.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 152 457.00 16909.00 37.00
TCON-TCON-TRANSITION CONFERENCE 1 1.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 152 516.50 18925.50 36.64
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 4 4.00 35.32 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 4 4.00 43.20 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.00 43.58 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.00 56.56 28.28
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.50 112.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.50 112.50 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 42 59.00 4425.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 39 55.00 4125.00 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 5.50 412.50 75.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.00 57.27 57.27
Subtotal (Total Children Is Unduplicated) 43 135.50 9423.43 69.55
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EI Services,Class #03
INTR-INTR-INTERPRETER 2 5.00 267.00 53.40
Subtotal (Total Children Is Unduplicated) 2 5.00 267.00 53.40
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Total 657.00 28615.93 43.56
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Number of Children (Unduplicated) With at Least One Service 154
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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 152 108.75 4023.75 0.00
P 67 57.00 2191.00 2191.00
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
613 491.25 22401.18 0.00
Other 0 0.00 0.00 0.00
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Total 832 657.00 28615.93 2191.00