CMS/EIP Fiscal Report Center: 06
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 533 283.50 10489.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 563 600.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 520 453.75 16788.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1066 2895.75 107133.50 37.00
TCON-TCON-TRANSITION CONFERENCE 152 160.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1496 4393.00 134411.75 30.60
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 20 20.00 176.60 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 18 18.00 194.40 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 17 17.00 370.43 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.00 28.28 28.28
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.00 75.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.00 75.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 25 37.50 2812.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 22 34.00 2550.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 15.00 1125.00 75.00
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 1 1.00 27.22 27.22
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 3 3.00 171.81 57.27
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 44 150.50 7703.24 51.18
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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 13 11.75 348.75 29.68
CONOP-CONOP-CONSULT, OT, PHONE 9 3.50 41.25 11.79
CONPF-CONPF-CONSULT, PT, FACE TO FACE 6 4.50 135.00 30.00
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
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 46 363.75 18187.50 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 218 1574.00 73690.00 46.82
INTR-INTR-INTERPRETER 16 78.75 4848.43 61.57
OCCT-97530-OT SESSION BY LICENSED OT 114 598.50 38244.92 63.90
OCCT-97530HM-OT SESSION BY OT ASST 13 51.25 2356.74 45.99
PHY-97110-PT SESSION BY LICENSED PT 135 517.00 30834.27 59.64
PHY-97110HM-PT SESSION BY PT ASST 1 4.00 217.28 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 459 2621.00 171593.27 65.47
TRAN-TRAN-FAMILY TRANSPORTATION 19 88.00 789.38 8.97
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 835 183242 91606.00 0.50
Subtotal (Total Children Is Unduplicated) 958 189222 436033.12 2.30
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Total 193765.00 578148.11 2.98
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Number of Children (Unduplicated) With at Least One Service 1694
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Center 06
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 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
14379 99497.00 368686.17 0.00
Other 0 0.00 0.00 0.00
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Total 21643 193765.00 578148.11 209461.94