CMS/EIP Fiscal Report Center: 10
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 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
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 4 4.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 6 5.50 203.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 157 279.00 10323.00 37.00
TCON-TCON-TRANSITION CONFERENCE 1 1.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 157 289.50 10526.50 36.36
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 2.00 2.98 1.49
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 2.00 2.80 1.40
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 2.00 7.32 3.66
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.00 4.75 4.75
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 6.00 450.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 4.00 300.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 0.50 37.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 7.00 525.00 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 11 14.00 1050.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 6.50 487.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 10 12.50 937.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 8 11.00 610.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 18 19.00 1425.00 75.00
Subtotal (Total Children Is Unduplicated) 27 92.50 6118.35 66.14
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 1.00 50.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 1 3.00 203.64 67.88
PHY-97110-PT SESSION BY LICENSED PT 1 1.00 67.88 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 35.00 17.50 0.50
Subtotal (Total Children Is Unduplicated) 3 40.00 339.02 8.48
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Total 422.00 16983.87 40.25
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Number of Children (Unduplicated) With at Least One Service 157
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Center 10
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 220 177.25 6775.00 0.00
P 35 45.75 2660.23 2660.23
D 7 7.50 277.50 277.50
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
184 191.50 7271.14 0.00
Other 0 0.00 0.00 0.00
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Total 446 422.00 16983.87 2937.73