CMS/EIP Fiscal Report Center: 06
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 536 285.75 10572.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 566 604.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 526 459.00 16983.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1810 4941.50 182826.25 37.00
TCON-TCON-TRANSITION CONFERENCE 152 160.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1821 6450.25 210382.00 32.62
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 228 228.00 2013.24 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 215 215.00 2322.00 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 209 209.00 4554.11 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 25 25.00 707.00 28.28
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 5.00 375.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 2.50 187.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 229 335.00 25125.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 140 199.00 14925.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 112 171.00 12825.00 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 10.50 787.50 75.00
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 9 9.00 244.98 27.22
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 35 35.00 2004.45 57.27
MED-99212-OUTPATIENT VISIT, EST, 10 MINS 1 1.00 18.17 18.17
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 2 2.00 69.00 34.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 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 13.00 649.88 49.99
Subtotal (Total Children Is Unduplicated) 332 1467.00 67173.83 45.79
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 6 6.00 1524.08 254.01
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 26 34.75 1012.50 29.14
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 4 3.00 90.00 30.00
CONIP-CONIP-CONSULT, ITDS, PHONE 6 3.50 52.50 15.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 14 12.25 373.75 30.51
CONOP-CONOP-CONSULT, OT, PHONE 9 3.50 41.25 11.79
CONPF-CONPF-CONSULT, PT, FACE TO FACE 8 6.00 200.00 33.33
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 14 14.50 435.00 30.00
CONSP-CONSP-CONSULT, SLP, PHONE 3 1.75 26.25 15.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.00 25.00 25.00
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 46 363.75 18187.50 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 294 2143.50 102165.00 47.66
INTR-INTR-INTERPRETER 16 78.75 4848.43 61.57
OCCT-97530-OT SESSION BY LICENSED OT 216 1245.00 82129.34 65.97
OCCT-97530HM-OT SESSION BY OT ASST 19 76.75 3741.90 48.75
PHY-97110-PT SESSION BY LICENSED PT 257 1286.50 83067.93 64.57
PHY-97110HM-PT SESSION BY PT ASST 3 13.50 733.32 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 655 3904.00 258348.91 66.18
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 2 9.50 516.04 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 4 10.50 138.60 13.20
TRAN-TRAN-FAMILY TRANSPORTATION 19 88.00 789.38 8.97
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 835 183252 91611.00 0.50
Subtotal (Total Children Is Unduplicated) 992 192558 650057.68 3.38
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Total 200475.25 927613.51 4.63
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Number of Children (Unduplicated) With at Least One Service 1942
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Center 06
Flag Claims Units Chgs Paid
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R 1 0.50 18.50 0.00
U 0 0.00 0.00 0.00
B 2972 1940.50 71798.50 0.00
P 7264 94268.00 209461.94 209461.94
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 0 0.00 0.00 0.00
19964 104266.25 646334.57 0.00
Other 0 0.00 0.00 0.00
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Total 30201 200475.25 927613.51 209461.94