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: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 23 7.25 268.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 27 25.00 925.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 97 393.00 14541.00 37.00
Subtotal (Total Children Is Unduplicated) 97 426.25 15734.25 36.91
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 2 2.00 17.66 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 3 3.00 32.40 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 3 3.00 65.37 21.79
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 38 46.00 3363.61 73.12
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 32 41.50 3112.50 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 6.00 450.00 75.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.00 57.27 57.27
Subtotal (Total Children Is Unduplicated) 48 105.50 7265.31 68.87
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
INTR-INTR-INTERPRETER 3 6.00 351.00 58.50
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 2 91.00 45.50 0.50
Subtotal (Total Children Is Unduplicated) 5 97.00 396.50 4.09
----------------------------------------------------------------------------------------------------------------
Total 628.75 23396.06 37.21
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 97
----------------------------------------------------------------------------------------------------------------
Center 06
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 151 126.75 4689.75 0.00
P 15 10.25 379.25 379.25
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
449 491.75 18327.06 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 615 628.75 23396.06 379.25