CMS/EIP Fiscal Report Center: 06
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 Page: 1
Payclass Filters:GR
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 20 11.75 434.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 4 4.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 39 39.00 1443.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 88 248.00 9176.00 37.00
Subtotal (Total Children Is Unduplicated) 105 302.75 11053.75 36.51
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.00 8.83 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.00 10.80 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.00 21.79 21.79
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.50 112.50 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.50 112.50 75.00
Subtotal (Total Children Is Unduplicated) 2 6.00 266.42 44.40
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EI Services,Class #03
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.00 25.00 25.00
OCCT-97530-OT SESSION BY LICENSED OT 1 1.50 101.82 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 90.00 45.00 0.50
Subtotal (Total Children Is Unduplicated) 2 92.50 171.82 1.86
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Total 401.25 11491.99 28.64
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Number of Children (Unduplicated) With at Least One Service 105
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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 7 92.50 171.82 171.82
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
430 308.75 11320.17 0.00
Other 0 0.00 0.00 0.00
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Total 437 401.25 11491.99 171.82