CMS/EIP Fiscal Report Center: 03
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 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 54 20.50 758.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 6 6.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 4 2.25 83.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 237 464.25 17177.25 37.00
Subtotal (Total Children Is Unduplicated) 237 493.00 18019.00 36.55
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Screening, Eval, and Assessment,Class #02
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.00 16.30 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 8 8.00 70.64 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 4 4.00 43.20 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 7 7.00 152.53 21.79
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.50 262.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 5.50 305.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 27 44.50 3337.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 13 40.00 1650.00 41.25
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 45 74.50 4134.75 55.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 135 135.00 6750.00 50.00
Subtotal (Total Children Is Unduplicated) 170 323.00 16722.67 51.77
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Total 816.00 34741.67 42.58
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Number of Children (Unduplicated) With at Least One Service 239
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Center 03
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 7 4.50 166.50 0.00
P 277 240.00 10245.25 10245.25
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 326 269.50 12112.75 12112.75
289 282.00 11934.50 0.00
Other 20 20.00 282.67 0.00
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Total 919 816.00 34741.67 22358.00