CMS/EIP Fiscal Report Center: 03
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Agency Filter:EIP DEI DEIP
Payclass Filters:GR
Eligibility Filter:Part C (excluding not eligible)
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 268 124.75 4615.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 455 569.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 138 161.00 5957.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 550 1353.25 50070.25 37.00
TCON-TCON-TRANSITION CONFERENCE 136 136.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 826 2344.00 60643.00 25.87
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Screening, Eval, and Assessment,Class #02
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 2 2.00 32.60 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 6 6.00 52.98 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 5 5.00 54.00 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 5 5.00 108.95 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.00 54.38 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.00 56.56 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.00 31.81 31.81
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 8.50 637.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.00 150.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 6.50 360.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 41 72.50 5437.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 11.00 825.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 41 72.50 4023.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.00 150.00 75.00
SCREEN-T1023-INTERDISCIPLINARY SCREENING 98 98.00 4900.00 50.00
Subtotal (Total Children Is Unduplicated) 136 295.00 16875.78 57.21
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 4 9.00 450.00 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 1 3.00 75.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 5.50 275.00 50.00
Subtotal (Total Children Is Unduplicated) 6 17.50 800.00 45.71
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Total 2656.50 78318.78 29.48
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Number of Children (Unduplicated) With at Least One Service 845
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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 0 0.00 0.00 0.00
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 3102 2491.50 72871.03 72852.53
198 165.00 5447.75 0.00
Other 0 0.00 0.00 0.00
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Total 3300 2656.50 78318.78 72852.53