CMS/EIP Fiscal Report Center: 10
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 2 3.25 120.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 5 5.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 103 111.75 4134.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 225 854.50 31616.50 37.00
Subtotal (Total Children Is Unduplicated) 226 974.50 35871.50 36.81
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 4 4.00 42.48 10.62
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 4 4.00 35.32 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 4 4.00 41.94 10.49
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 3 3.00 65.37 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 4 4.00 92.95 23.24
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 9.50 712.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 9.00 675.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 6.00 450.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.00 225.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 4.00 222.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 117 189.50 14212.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 67 101.00 7575.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 48 68.50 5137.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 61 94.00 5217.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 58 80.00 6000.00 75.00
Subtotal (Total Children Is Unduplicated) 169 583.50 40704.56 69.76
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Total 1558.00 76576.06 49.15
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Number of Children (Unduplicated) With at Least One Service 227
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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 362 337.75 12828.50 0.00
P 140 197.50 13255.81 13255.81
D 11 6.25 231.25 185.00
S 12 8.75 323.75 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
933 1007.75 49936.75 0.00
Other 0 0.00 0.00 0.00
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Total 1458 1558.00 76576.06 13440.81