CMS/EIP Fiscal Report Center: 06
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 34 17.25 638.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 9 9.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 27 25.75 952.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 135 366.75 13569.75 37.00
Subtotal (Total Children Is Unduplicated) 135 418.75 15160.75 36.20
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.00 8.83 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.00 10.80 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.00 21.79 21.79
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.50 112.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.50 112.50 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 27 36.50 2737.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 15 19.00 1425.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 11 16.00 1200.00 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.50 112.50 75.00
Subtotal (Total Children Is Unduplicated) 28 79.00 5741.42 72.68
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EI Services,Class #03
INTR-INTR-INTERPRETER 1 2.00 117.00 58.50
PHY-97110-PT SESSION BY LICENSED PT 1 1.50 101.82 67.88
TRAN-TRAN-FAMILY TRANSPORTATION 1 1.00 10.80 10.80
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 2 130.00 65.00 0.50
Subtotal (Total Children Is Unduplicated) 2 134.50 294.62 2.19
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Total 632.25 21196.79 33.53
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Number of Children (Unduplicated) With at Least One Service 135
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Center 06
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 194 139.00 5143.00 0.00
P 113 212.25 3241.05 3241.05
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
365 281.00 12812.74 0.00
Other 0 0.00 0.00 0.00
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Total 672 632.25 21196.79 3241.05