CMS/EIP Fiscal Report Center: 03
Services beginning 10/01/2008 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 11 4.50 166.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 4 3.00 111.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 177 298.75 11053.75 37.00
Subtotal (Total Children Is Unduplicated) 178 307.25 11331.25 36.88
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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 1 1.00 16.30 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 9 9.00 79.47 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 3 3.00 32.40 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 8 8.00 174.32 21.79
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 13 21.00 1575.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.50 112.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 13 21.00 1165.50 55.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 125 125.00 6250.00 50.00
Subtotal (Total Children Is Unduplicated) 134 190.50 9416.11 49.43
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 2.00 100.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 1.00 50.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 1 1.00 25.00 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.00 50.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.00 25.00 25.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 120.00 60.00 0.50
Subtotal (Total Children Is Unduplicated) 1 126.00 310.00 2.46
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Total 623.75 21057.36 33.76
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Number of Children (Unduplicated) With at Least One Service 188
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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 86 82.00 3497.25 0.00
P 115 200.00 4056.25 4043.25
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 307 285.25 12453.25 12453.25
15 32.50 663.50 0.00
Other 22 22.00 313.11 0.00
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Total 550 623.75 21057.36 16496.50