CMS/EIP Fiscal Report Center: 06
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 Page: 1
Agency Filter:EIP DEI DEIP
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 395 212.25 7853.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 620 643.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 395 367.50 13597.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1679 5140.50 190198.50 37.00
TCON-TCON-TRANSITION CONFERENCE 152 152.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1688 6515.25 211649.25 32.49
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 98 99.00 874.17 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 95 96.00 1036.80 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 93 94.00 2048.26 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 3.00 84.84 28.28
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 5.00 375.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 7.50 562.50 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 185 265.00 19875.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 176 249.50 18712.50 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 14 25.00 1875.00 75.00
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 2 2.00 54.44 27.22
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 25 25.00 1431.75 57.27
Subtotal (Total Children Is Unduplicated) 312 871.00 46930.26 53.88
----------------------------------------------------------------------------------------------------------------
Total 7386.25 258579.51 35.01
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1697
----------------------------------------------------------------------------------------------------------------
Center 06
Flag Claims Units Chgs Paid
-------------------------------------------------
R 25 14.75 545.75 0.00
U 0 0.00 0.00 0.00
B 165 105.00 3885.00 434.75
P 3484 2242.75 83418.75 83418.75
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
7006 5023.75 170730.01 1082.25
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 10680 7386.25 258579.51 84935.75