CMS/EIP Fiscal Report Center: 06
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 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 426 249.50 9231.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 634 663.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 432 385.75 14272.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 935 2917.75 107956.75 37.00
TCON-TCON-TRANSITION CONFERENCE 197 197.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1344 4413.00 131461.00 29.79
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 16 16.00 141.28 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 16 16.00 172.80 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 16 16.00 348.64 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.00 56.56 28.28
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 17 28.00 2100.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 16 28.00 2100.00 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 5 5.00 286.35 57.27
Subtotal (Total Children Is Unduplicated) 30 116.50 5618.13 48.22
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EI Services,Class #03
CONOF-CONOF-CONSULT, OT, FACE TO FACE 2 2.25 112.50 50.00
INTR-INTR-INTERPRETER 1 2.00 100.00 50.00
SPL-92508-GROUP SPL SESSION PER CHILD 5 38.75 511.50 13.20
Subtotal (Total Children Is Unduplicated) 8 43.00 724.00 16.84
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Total 4572.50 137803.13 30.14
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Number of Children (Unduplicated) With at Least One Service 1348
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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 0 0.00 0.00 0.00
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
6514 4572.50 137803.13 795.50
Other 0 0.00 0.00 0.00
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Total 6514 4572.50 137803.13 795.50