CMS/EIP Fiscal Report Center: 01
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Payclass Filters:GR
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 924 574.50 21256.50 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 687 674.50 24956.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1337 3350.75 123959.25 36.99
Subtotal (Total Children Is Unduplicated) 1957 4599.75 170172.25 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 6 5.75 287.50 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 24 41.50 2075.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 10 13.00 975.00 75.00
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 8 12.50 937.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 15 21.50 1193.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 148 190.50 14131.91 74.18
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 48 73.00 5475.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 151 227.00 12598.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 37 51.50 3862.50 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 7 7.00 339.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 5 5.00 242.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 13 13.00 630.50 48.50
Subtotal (Total Children Is Unduplicated) 316 693.25 44710.87 64.49
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 6 11.00 2118.85 192.62
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 42 76.00 3800.00 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 6 2.50 62.50 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 14 8.75 437.50 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 14 11.75 587.50 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 4 1.50 37.50 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 43 692.25 7185.00 10.38
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 11 56.00 2800.00 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 5 13.25 662.50 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 169 999.50 49905.00 49.93
INTR-INTR-INTERPRETER 17 56.75 1802.50 31.76
OCCT-97530-OT SESSION BY LICENSED OT 53 357.25 23197.80 64.93
OCCT-97530HM-OT SESSION BY OT ASST 1 1.00 54.32 54.32
PHY-97110-PT SESSION BY LICENSED PT 99 479.00 31555.41 65.88
PHY-97110HM-PT SESSION BY PT ASST 1 0.75 34.14 45.52
RSPT-RSPT-RESPITE 1 78.00 634.00 8.13
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 500 3418.75 231120.55 67.60
TRAN-TRAN-FAMILY TRANSPORTATION 1 106.00 10600.00 100.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 904 217053 108515.50 0.50
Subtotal (Total Children Is Unduplicated) 1023 223431 475310.57 2.13
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Total 228724.00 690193.69 3.02
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Number of Children (Unduplicated) With at Least One Service 2177
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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 4003 115115.50 259933.49 259797.73
D 0 0.00 0.00 0.00
S 485 301.75 11164.75 0.00
H 13 14.50 1019.25 0.00
T 3459 92006.75 198695.70 198695.70
8584 13797.75 198873.71 0.00
Other 420 7487.75 20506.79 0.00
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Total 16964 228724.00 690193.69 458493.43