CMS/EIP Fiscal Report Center: 06
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 16 8.00 296.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 2 2.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 61 54.00 1998.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 84 275.25 10175.00 36.97
Subtotal (Total Children Is Unduplicated) 105 339.25 12469.00 36.75
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.00 8.83 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.00 10.80 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.00 21.79 21.79
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.00 75.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 2.50 187.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 3.00 225.00 75.00
Subtotal (Total Children Is Unduplicated) 4 9.50 528.92 55.68
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EI Services,Class #03
INTR-INTR-INTERPRETER 2 4.00 234.00 58.50
TRAN-TRAN-FAMILY TRANSPORTATION 2 2.00 21.60 10.80
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 2 90.00 45.00 0.50
Subtotal (Total Children Is Unduplicated) 2 96.00 300.60 3.13
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Total 444.75 13298.52 29.90
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Number of Children (Unduplicated) With at Least One Service 107
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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 3 48.00 150.30 150.30
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
469 396.75 13148.22 0.00
Other 0 0.00 0.00 0.00
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Total 472 444.75 13298.52 150.30