CMS/EIP Fiscal Report Center: 10
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Payclass Filters:GR
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 62 99.50 3681.50 37.00
TCON-TCON-TRANSITION CONFERENCE 1 1.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 70 110.00 3885.00 35.32
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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
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 6 6.00 450.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 3.00 225.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 8.50 637.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 2.00 111.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 11.00 825.00 75.00
Subtotal (Total Children Is Unduplicated) 13 37.50 2266.35 60.44
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EI Services,Class #03
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) 2 36.00 85.38 2.37
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Total 183.50 6236.73 33.99
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Number of Children (Unduplicated) With at Least One Service 71
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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 0 0.00 0.00 0.00
P 9 8.00 85.73 85.73
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
172 175.50 6151.00 0.00
Other 0 0.00 0.00 0.00
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Total 181 183.50 6236.73 85.73