CMS/EIP Fiscal Report Center: 03
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/16/2009 Page: 1
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 75 38.00 1406.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 12 13.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 30 26.50 980.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 450 1545.75 57185.50 37.00
Subtotal (Total Children Is Unduplicated) 450 1623.25 59572.00 36.70
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.00 10.62 10.62
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 2 2.00 32.60 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 32 32.00 277.16 8.66
AUDE-92557-COMP AUDIO THRESHOLD EVAL/SPCH RECOG 1 1.00 27.10 27.10
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 14 14.00 149.94 10.71
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 30 30.00 624.96 20.83
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.00 54.38 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.00 55.47 27.74
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 2.00 100.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.50 112.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 8 11.00 825.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 4.50 337.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 6 8.00 600.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 7 11.00 610.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 71 107.50 8062.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 163 243.50 18262.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 32 45.50 3412.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 127 194.00 10767.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 128 189.50 14212.50 75.00
SCREEN-T1023-INTERDISCIPLINARY SCREENING 136 136.00 6800.00 50.00
Subtotal (Total Children Is Unduplicated) 398 1037.00 65334.73 63.00
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 3 6.00 300.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 2.00 100.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 1 1.00 25.00 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 2 3.00 150.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.00 25.00 25.00
INTR-INTR-INTERPRETER 7 21.25 1132.50 53.29
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 8 960.00 480.00 0.50
Subtotal (Total Children Is Unduplicated) 12 994.25 2212.50 2.23
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Total 3654.50 127119.23 34.78
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Number of Children (Unduplicated) With at Least One Service 466
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Center 03
Flag Claims Units Chgs Paid
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R 5 2.00 74.00 0.00
U 0 0.00 0.00 0.00
B 123 122.25 5676.75 0.00
P 854 1647.75 30091.00 30050.25
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 1829 1767.50 89027.82 89341.94
27 43.00 1212.75 0.00
Other 72 72.00 1036.91 0.00
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Total 2910 3654.50 127119.23 119392.19