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
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 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 886 2611.25 96616.25 37.00
TCON-TCON-TRANSITION CONFERENCE 152 152.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1335 3986.00 118067.00 29.62
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 14 14.00 123.62 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 14 14.00 151.20 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 14 14.00 305.06 21.79
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 10 13.50 1012.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 11 18.00 1350.00 75.00
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 1 1.00 27.22 27.22
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.00 57.27 57.27
Subtotal (Total Children Is Unduplicated) 25 75.50 3026.87 40.09
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Total 4061.50 121093.87 29.82
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Number of Children (Unduplicated) With at Least One Service 1337
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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
6072 4061.50 121093.87 1082.25
Other 0 0.00 0.00 0.00
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Total 6072 4061.50 121093.87 1082.25