CMS/EIP Fiscal Report Center: 54
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 276 116.75 4319.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 205 209.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 500 581.00 21413.75 36.86
TCM-T1017TL-TARGETED CASE MANAGEMENT 600 1755.25 64093.25 36.52
Subtotal (Total Children Is Unduplicated) 980 2662.00 89826.75 33.74
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 2 2.00 17.66 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 14 14.00 151.20 10.80
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 6 6.00 50.64 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 14 14.00 305.06 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.00 54.38 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 9 9.00 254.52 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 2 2.00 63.62 31.81
EVAL-EVAL-DEVELOPMENTAL EVALUATION 2 1.25 62.50 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 8.50 637.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 8 8.00 600.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 4.00 300.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 8 8.50 471.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 35 47.50 3562.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 69 72.00 5400.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 7.00 525.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 52 65.50 3635.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 44 51.50 3862.50 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 7 7.15 346.68 48.49
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 3 3.00 145.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 20 18.00 873.00 48.50
Subtotal (Total Children Is Unduplicated) 207 353.90 21539.76 60.86
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 5 4.75 237.50 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 41 35.25 1762.50 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 2 1.75 43.75 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 34 33.75 1687.50 50.00
CONOP-CONOP-CONSULT, OT, PHONE 2 0.50 12.50 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 12 7.25 362.50 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 52 44.25 2212.50 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 1 0.50 12.50 25.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 7 127.00 6350.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 147 1107.00 55300.00 49.95
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 2 2.00 100.00 50.00
INTR-INTR-INTERPRETER 23 101.00 5050.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 115 675.24 45825.17 67.87
PHY-97110-PT SESSION BY LICENSED PT 41 157.42 10576.80 67.19
PHY-97110HM-PT SESSION BY PT ASST 1 1.00 54.32 54.32
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 3 5.00 250.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 127 710.98 48249.64 67.86
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 597 154888 132050.05 0.85
Subtotal (Total Children Is Unduplicated) 694 157903 310137.23 1.96
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Total 160918.54 421503.74 2.62
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Number of Children (Unduplicated) With at Least One Service 1146
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Center 54
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 2621 131483.27 291271.92 291271.92
D 0 0.00 0.00 0.00
S 1 98.00 235.80 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
4487 29337.27 129996.02 0.00
Other 0 0.00 0.00 0.00
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Total 7109 160918.54 421503.74 291271.92