CMS/EIP Fiscal Report Center: 54
Services beginning 01/01/2008 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 128 55.25 2044.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 22 22.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 369 507.00 18703.50 36.89
TCM-T1017TL-TARGETED CASE MANAGEMENT 486 2403.75 87764.00 36.51
Subtotal (Total Children Is Unduplicated) 486 2988.00 108511.75 36.32
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Screening, Eval, and Assessment,Class #02
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.00 10.38 10.38
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.00 37.39 37.39
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 9 10.50 787.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 11 11.50 1050.00 91.30
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 25 28.50 3300.00 115.79
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 23 25.50 1415.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 53 66.00 4875.00 73.86
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 155 169.50 13050.00 76.99
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 11 12.00 900.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 160 181.00 10045.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 252 290.50 30009.39 103.30
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 2.00 97.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 2 2.00 97.00 48.50
Subtotal (Total Children Is Unduplicated) 401 802.00 65749.41 81.98
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 7.00 350.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 1 4.00 271.52 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 4.75 322.43 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 281 13175.0 12140.50 0.92
Subtotal (Total Children Is Unduplicated) 281 13190.8 13084.45 0.99
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Total 16980.75 187345.61 11.03
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Number of Children (Unduplicated) With at Least One Service 514
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Center 54
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 575 414.50 15847.50 0.00
P 1663 9969.13 69884.27 66875.98
D 41 29.50 1373.50 144.38
S 1 1.50 262.50 2.65
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
2766 6566.12 99977.84 63.29
Other 0 0.00 0.00 0.00
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Total 5046 16980.75 187345.61 67086.30