CMS/EIP Fiscal Report Center: 10
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/16/2009 Page: 1
Payclass Filters:GR
Eligibility Filter:DEI Only
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 137 140.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 24 26.50 980.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 162 499.25 18472.25 37.00
TCON-TCON-TRANSITION CONFERENCE 3 3.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 263 668.75 19452.75 29.09
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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-92555-SPEECH AUD THRESHOLD (DETECTION) 2 3.00 11.81 3.94
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 3.00 13.18 4.39
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 3.00 29.11 9.70
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.00 33.03 16.52
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.50 262.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.00 75.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.50 112.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 6.00 333.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 21 27.50 2062.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 4.00 300.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 20 25.00 1875.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 33 45.00 2497.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 55 54.00 4050.00 75.00
Subtotal (Total Children Is Unduplicated) 65 180.50 11740.75 65.05
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EI Services,Class #03
PHY-97110-PT SESSION BY LICENSED PT 1 3.00 203.64 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 35.00 17.50 0.50
Subtotal (Total Children Is Unduplicated) 2 38.00 221.14 5.82
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Total 887.25 31414.64 35.41
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Number of Children (Unduplicated) With at Least One Service 264
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Center 10
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 16 15.00 301.39 301.39
D 11 7.75 438.75 438.75
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
848 864.50 30674.50 0.00
Other 0 0.00 0.00 0.00
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Total 875 887.25 31414.64 740.14