CMS/EIP Fiscal Report Center: 02
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 156 60.00 2201.50 36.69
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 136 139.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 166 271.00 9980.75 36.83
TCM-T1017TL-TARGETED CASE MANAGEMENT 175 427.00 15788.75 36.98
TCON-TCON-TRANSITION CONFERENCE 9 9.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 395 906.00 27971.00 30.87
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 1.00 115.00 115.00
EVAL-EVAL-DEVELOPMENTAL EVALUATION 2 2.50 125.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 6 8.00 400.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.00 150.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.00 166.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 44 73.50 5475.00 74.49
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 17 24.50 1837.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 12.00 900.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 40 67.00 3718.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.50 112.50 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 3 3.00 145.50 48.50
Subtotal (Total Children Is Unduplicated) 84 199.00 13194.00 66.30
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 8 17.00 1578.09 92.83
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 7 5.75 272.50 47.39
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 4 4.50 225.00 50.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 11 6.00 300.00 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 0.50 25.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 14 13.00 650.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 4 1.50 37.50 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 45 272.50 13625.00 50.00
INTR-INTR-INTERPRETER 3 9.50 475.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 22 133.00 9002.69 67.69
PHY-97110-PT SESSION BY LICENSED PT 8 26.25 1699.18 64.73
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 1 1.00 399.00 399.00
SENS-V5264-EARMOLD 2 6.00 90.72 15.12
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 64 449.25 30227.59 67.28
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 229 60355.0 30072.50 0.50
Subtotal (Total Children Is Unduplicated) 259 61300.8 88679.77 1.45
----------------------------------------------------------------------------------------------------------------
Total 62405.75 129844.77 2.08
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 485
----------------------------------------------------------------------------------------------------------------
Center 02
Flag Claims Units Chgs Paid
-------------------------------------------------
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 1082 41619.75 67236.12 67236.12
1610 20779.00 62455.65 678.88
Other 2 7.00 153.00 0.00
-------------------------------------------------
Total 2694 62405.75 129844.77 67915.00