CMS/EIP Fiscal Report Center: 01
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Eligibility Filter:Program Patients
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 932 578.75 21413.75 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 704 693.25 25650.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 2547 6921.75 256086.25 37.00
Subtotal (Total Children Is Unduplicated) 2567 8193.75 303150.25 37.00
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 6 6.00 220.50 36.75
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.00 10.62 10.62
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.00 10.80 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.00 21.79 21.79
EVAL-EVAL-DEVELOPMENTAL EVALUATION 7 8.75 437.50 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 24 41.50 2075.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 17 22.00 1612.50 73.30
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 5.00 375.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 26 41.00 3075.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 32 46.00 2553.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 195 258.75 19323.50 74.68
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 14 17.00 1275.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 49 75.00 5625.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 264 379.50 21031.50 55.42
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 138 187.50 14062.50 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 9 9.00 451.42 50.16
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 4 4.00 194.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 5 5.00 242.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 21 21.00 1355.49 64.55
Subtotal (Total Children Is Unduplicated) 534 1130.00 73952.62 65.44
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 6 13.00 2188.67 168.36
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 44 78.00 3900.00 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 6 2.50 62.50 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 15 9.75 487.50 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 10 5.25 131.25 25.00
CONPP-CONPP-CONSULT, PT, PHONE 7 2.75 68.75 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 16 19.00 950.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 4 1.50 37.50 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 43 697.25 7305.00 10.48
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 11 56.00 2800.00 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 8 35.50 1775.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 303 1588.50 79271.63 49.90
INTR-INTR-INTERPRETER 17 56.75 1802.50 31.76
OCCT-97530-OT SESSION BY LICENSED OT 92 554.75 40792.42 73.53
OCCT-97530HM-OT SESSION BY OT ASST 5 17.00 989.12 58.18
PHY-97110-PT SESSION BY LICENSED PT 173 910.50 62250.82 68.37
PHY-97110HM-PT SESSION BY PT ASST 4 53.25 2912.88 54.70
RSPT-RSPT-RESPITE 1 78.00 634.00 8.13
SENS-V5264-EARMOLD 1 1.00 18.72 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 581 4157.75 282879.78 68.04
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.00 100.00 100.00
TRAN-TRAN-FAMILY TRANSPORTATION 1 106.00 10600.00 100.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 904 217269 108623.50 0.50
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 26 158.00 7900.00 50.00
Subtotal (Total Children Is Unduplicated) 1101 225872 618481.54 2.74
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Total 235195.75 995584.41 4.23
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Number of Children (Unduplicated) With at Least One Service 2613
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Center 01
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 4007 115127.75 262021.22 261727.21
D 0 0.00 0.00 0.00
S 1577 997.00 36916.75 0.00
H 49 58.00 3846.50 0.00
T 3640 92241.25 214148.12 214148.12
9911 16238.00 338381.28 0.00
Other 5024 10533.75 140270.54 0.00
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Total 24208 235195.75 995584.41 475875.33