CMS/EIP Fiscal Report Center: 06
Services beginning 04/01/2010 ending 06/30/2010 Date of Report:08/18/2010 Page: 1
Eligibility Filter:DEI Only
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 5 4.25 157.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 18 18.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 25 22.50 832.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 62 186.00 6882.00 37.00
TCON-TCON-TRANSITION CONFERENCE 2 2.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 62 232.75 7871.75 33.82
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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 5 6.00 450.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 6.50 487.50 75.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.00 57.27 57.27
Subtotal (Total Children Is Unduplicated) 6 19.50 1077.61 55.26
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 7 36.00 1800.00 50.00
INTR-INTR-INTERPRETER 1 8.00 520.00 65.00
OCCT-97530-OT SESSION BY LICENSED OT 2 11.00 746.68 67.88
PHY-97110-PT SESSION BY LICENSED PT 1 2.50 169.70 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 20.25 1182.57 58.40
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 12 1607.00 803.50 0.50
Subtotal (Total Children Is Unduplicated) 13 1684.75 5222.45 3.10
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Total 1937.00 14171.81 7.32
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Number of Children (Unduplicated) With at Least One Service 63
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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 224 147.75 5466.75 0.00
P 20 16.25 601.25 601.25
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
255 1773.00 8103.81 0.00
Other 0 0.00 0.00 0.00
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Total 499 1937.00 14171.81 601.25