CMS/EIP Fiscal Report Center: 03
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 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 12 6.50 240.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 8 4.25 157.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 67 211.50 7825.50 37.00
Subtotal (Total Children Is Unduplicated) 78 223.25 8223.25 36.83
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Screening, Eval, and Assessment,Class #02
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 10.00 163.00 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 2 11.00 97.13 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 11.00 118.80 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.00 21.79 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.00 54.38 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.00 28.28 28.28
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 4.50 337.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.00 225.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.50 83.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 23 40.00 3000.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 26 43.00 3225.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 34 59.00 3274.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 18 27.50 2062.50 75.00
SCREEN-T1023-INTERDISCIPLINARY SCREENING 10 10.00 500.00 50.00
Subtotal (Total Children Is Unduplicated) 69 223.50 13191.13 59.02
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.00 50.00 50.00
INTR-INTR-INTERPRETER 4 11.00 550.00 50.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 5 116.00 58.00 0.50
Subtotal (Total Children Is Unduplicated) 6 128.00 658.00 5.14
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Total 574.75 22072.38 38.40
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Number of Children (Unduplicated) With at Least One Service 98
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Center 03
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 22 152.00 2263.00 2263.00
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 359 422.75 19809.38 19809.38
0 0.00 0.00 0.00
Other 0 0.00 0.00 0.00
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Total 381 574.75 22072.38 22072.38