CMS/EIP Fiscal Report Center: 06
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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 21 10.75 397.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 3 3.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 18 21.50 795.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 95 366.25 13551.25 37.00
Subtotal (Total Children Is Unduplicated) 95 401.50 14744.50 36.72
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 2 2.00 17.66 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.00 21.60 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.00 43.58 21.79
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 44 52.50 3937.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 43 49.00 3675.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 3.00 166.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 5.50 412.50 75.00
Subtotal (Total Children Is Unduplicated) 58 116.00 8274.34 71.33
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EI Services,Class #03
INTR-INTR-INTERPRETER 6 12.00 695.00 57.92
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 3.00 203.64 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 246.00 123.00 0.50
Subtotal (Total Children Is Unduplicated) 7 261.00 1021.64 3.91
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Total 778.50 24040.48 30.88
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Number of Children (Unduplicated) With at Least One Service 95
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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 12 7.00 259.00 0.00
P 163 128.25 4907.25 4907.25
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
468 643.25 18874.23 225.00
Other 0 0.00 0.00 0.00
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Total 643 778.50 24040.48 5132.25