CMS/EIP Fiscal Report Center: 10
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/16/2009 Page: 1
Payclass Filters:GR
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 132 516.50 19110.50 37.00
Subtotal (Total Children Is Unduplicated) 172 636.50 23365.50 36.71
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 3 3.00 31.86 10.62
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 3 3.00 26.49 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 3 3.00 31.14 10.38
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 1 2.00 150.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.00 150.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 27 42.50 3187.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 16 24.00 1800.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 17 21.50 1612.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 16 25.50 1415.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 20 24.50 1837.50 75.00
Subtotal (Total Children Is Unduplicated) 49 158.00 10400.56 65.83
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Total 794.50 33766.06 42.50
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Number of Children (Unduplicated) With at Least One Service 179
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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 16.00 247.81 247.81
D 9 5.25 194.25 148.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
788 773.25 33324.00 0.00
Other 0 0.00 0.00 0.00
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Total 813 794.50 33766.06 395.81