CMS/EIP Fiscal Report Center: 06
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/15/2010 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 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 55 215.25 7964.25 37.00
Subtotal (Total Children Is Unduplicated) 67 250.50 9157.50 36.56
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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
Subtotal (Total Children Is Unduplicated) 1 3.00 41.42 13.81
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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 514.50 10220.56 19.87
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Number of Children (Unduplicated) With at Least One Service 70
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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 2 4.00 234.00 234.00
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
345 510.50 9986.56 0.00
Other 0 0.00 0.00 0.00
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Total 347 514.50 10220.56 234.00