CMS/EIP Fiscal Report Center: 51
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 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 26 19.00 703.00 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 32 50.00 1850.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 59 266.75 9869.75 37.00
Subtotal (Total Children Is Unduplicated) 59 335.75 12422.75 37.00
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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
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.00 28.28 28.28
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 1.00 50.00 50.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 23 24.50 1837.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 3.50 262.50 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 26 28.00 2062.50 73.66
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.00 97.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 30 64.00 4427.70 69.18
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 6.00 300.00 50.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 22 1161.00 550.50 0.47
Subtotal (Total Children Is Unduplicated) 22 1167.00 850.50 0.73
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Total 1566.75 17700.95 11.30
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Number of Children (Unduplicated) With at Least One Service 60
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Center 51
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 194 171.75 6753.75 0.00
P 55 1183.50 1892.20 1892.20
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
283 211.50 9055.00 0.00
Other 0 0.00 0.00 0.00
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Total 532 1566.75 17700.95 1892.20