CMS/EIP Fiscal Report Center: 03
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/16/2009 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 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 275 893.75 33061.50 36.99
Subtotal (Total Children Is Unduplicated) 323 971.25 35448.00 36.50
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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) 3 3.00 25.59 8.53
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 3 3.00 31.98 10.66
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.00 38.79 19.40
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.00 54.38 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.00 28.28 28.28
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 7 9.50 712.50 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 6 9.50 527.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 62 95.50 7162.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 147 220.00 16500.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 30 43.00 3225.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 112 172.50 9573.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 116 171.50 12862.50 75.00
SCREEN-T1023-INTERDISCIPLINARY SCREENING 100 100.00 5000.00 50.00
Subtotal (Total Children Is Unduplicated) 337 848.50 56908.82 67.07
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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 2814.00 94569.32 33.61
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Number of Children (Unduplicated) With at Least One Service 399
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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 66 1006.00 4421.25 4421.25
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
24 40.50 1120.25 0.00
Other 0 0.00 0.00 0.00
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Total 1919 2814.00 94569.32 93763.19