CMS/EIP Fiscal Report Center: 09
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 791 733.75 27139.75 36.99
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 428 464.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 649 670.25 24743.75 36.92
TCM-T1017TL-TARGETED CASE MANAGEMENT 901 2757.75 101879.50 36.94
TCON-TCON-TRANSITION CONFERENCE 66 69.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1431 4694.75 153763.00 32.75
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Screening, Eval, and Assessment,Class #02
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 2.00 93.60 46.80
EVAL-EVAL-DEVELOPMENTAL EVALUATION 14 13.00 650.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 14 22.00 1650.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 9 14.00 1050.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 6.00 450.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 7.00 525.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 7 9.00 499.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 85 156.00 11700.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 74 148.00 11100.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 37 60.00 4500.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 82 140.50 7797.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 10.00 750.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 2 2.00 97.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 2.00 97.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 16 16.00 800.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 6 6.00 291.00 48.50
Subtotal (Total Children Is Unduplicated) 214 615.50 42147.85 68.48
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EI Services,Class #03
AUD-HA_FUP-AUDIOLOGY SERVICES 1 1.00 50.00 50.00
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 57 69.25 3462.50 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 1 0.50 12.50 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 13 33.50 1675.00 50.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 16 28.00 1400.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 2 0.50 12.50 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 10 25.75 1287.50 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 38 45.75 2287.50 50.00
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 9 28.00 2055.76 73.42
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 229 1841.00 88550.00 48.10
INTR-INTR-INTERPRETER 20 78.25 3912.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 206 1125.50 74718.61 66.39
OCCT-97530HM-OT SESSION BY OT ASST 5 9.50 516.04 54.32
PHY-97110-PT SESSION BY LICENSED PT 152 758.00 49360.45 65.12
PHY-97110HM-PT SESSION BY PT ASST 2 7.00 380.24 54.32
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 1 2.00 1000.00 500.00
SENS-V5264-EARMOLD 1 2.00 37.44 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 412 2663.25 178790.56 67.13
SPL-92508-GROUP SPL SESSION PER CHILD 2 2.00 26.40 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 714 147947 73966.00 0.50
Subtotal (Total Children Is Unduplicated) 924 154668 483501.50 3.13
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Total 159978.00 679412.35 4.25
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Number of Children (Unduplicated) With at Least One Service 1668
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Center 09
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 17 13.75 521.75 0.00
P 5171 85823.50 349362.04 349362.04
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 2737 68913.50 195750.15 195750.15
4972 5227.25 133778.41 1145.92
Other 0 0.00 0.00 0.00
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Total 12897 159978.00 679412.35 546258.11