CMS/EIP Fiscal Report Center: 03
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 Page: 1
Agency Filter:EIP DEI DEIP
Payclass Filters:GR
Eligibility Filter:Part C (excluding not eligible)
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 751 454.00 16798.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 623 792.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 172 186.00 6882.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 531 1556.75 57599.75 37.00
TCON-TCON-TRANSITION CONFERENCE 142 142.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 999 3130.75 81279.75 25.96
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.00 10.62 10.62
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 6 6.00 52.98 8.83
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 5 5.00 108.95 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.00 28.28 28.28
EXIT-EXIT-TRANSITION ASSESSMENT 67 105.50 5275.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 6.00 450.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 7 12.00 666.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 50 81.00 6075.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 12 23.00 1725.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 108 197.00 10933.50 55.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 9 9.00 450.00 50.00
Subtotal (Total Children Is Unduplicated) 195 446.50 25775.33 57.73
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 6 9.00 450.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 4 3.25 162.50 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.00 50.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 8 18.00 900.00 50.00
Subtotal (Total Children Is Unduplicated) 15 31.25 1562.50 50.00
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Total 3608.50 108617.58 30.10
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Number of Children (Unduplicated) With at Least One Service 1010
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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 0 0.00 0.00 0.00
P 0 0.00 0.00 0.00
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 3729 2522.00 75441.09 75441.09
1662 1082.50 33115.25 0.00
Other 4 4.00 61.24 0.00
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Total 5395 3608.50 108617.58 75441.09