CMS/EIP Fiscal Report Center: 54
Services beginning 01/01/2008 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 128 55.25 2044.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 20 20.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 369 505.50 18648.00 36.89
TCM-T1017TL-TARGETED CASE MANAGEMENT 269 1231.00 45010.50 36.56
Subtotal (Total Children Is Unduplicated) 450 1811.75 65702.75 36.26
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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 3 3.50 262.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 7 7.00 525.00 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 6 6.00 450.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 9 11.00 610.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 38 48.50 3562.50 73.45
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 119 121.84 9137.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 5.50 412.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 75 85.50 4745.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 86 95.34 7150.00 74.99
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 0.70 33.50 47.86
Subtotal (Total Children Is Unduplicated) 248 387.88 27012.02 69.64
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 1 2.00 135.76 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 13181.8 12598.69 0.96
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Total 15381.38 105313.46 6.85
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Number of Children (Unduplicated) With at Least One Service 481
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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 0 0.00 0.00 0.00
P 562 9104.63 30064.26 30064.26
D 40 28.50 1111.00 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
2479 6248.25 74138.20 0.00
Other 0 0.00 0.00 0.00
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Total 3081 15381.38 105313.46 30064.26