CMS/EIP Fiscal Report Center: 03
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 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 194 95.25 3524.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 466 583.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 103 131.25 4856.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 494 1182.50 43752.50 37.00
TCON-TCON-TRANSITION CONFERENCE 87 87.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 730 2079.00 52133.00 25.08
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Screening, Eval, and Assessment,Class #02
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.00 16.30 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 8 8.00 70.64 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 4 4.00 43.20 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 7 7.00 152.53 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.00 54.38 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.00 56.56 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.00 31.81 31.81
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 5.50 412.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 5.00 375.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.50 262.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 5.00 277.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 40 74.50 5587.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 44 75.50 5662.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 48 87.00 4828.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 36 61.50 4612.50 75.00
SCREEN-T1023-INTERDISCIPLINARY SCREENING 5 5.00 250.00 50.00
Subtotal (Total Children Is Unduplicated) 110 346.50 22693.92 65.49
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 12 20.50 1025.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 7 22.00 1100.00 50.00
Subtotal (Total Children Is Unduplicated) 15 42.50 2125.00 50.00
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Total 2468.00 76951.92 31.18
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Number of Children (Unduplicated) With at Least One Service 741
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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 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 2880 2459.50 76711.42 76711.42
21 8.50 240.50 0.00
Other 0 0.00 0.00 0.00
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Total 2901 2468.00 76951.92 76711.42