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:TPIN
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
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 2 2.00 262.50 131.25
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 5 3.25 120.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 40 61.25 2210.75 36.09
Subtotal (Total Children Is Unduplicated) 42 66.50 2593.50 39.00
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.00 10.62 10.62
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.00 16.30 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 12 12.00 105.96 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 18 19.00 205.20 10.80
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 3 3.00 25.32 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 12 12.00 261.48 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.00 54.38 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.00 28.28 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 7 7.00 222.67 31.81
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 9.00 675.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 5.50 600.00 109.09
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 5.50 750.00 136.36
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 9 11.00 1012.50 92.05
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 12.50 1425.00 114.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 3.50 262.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 3.00 166.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 17 21.50 2250.00 104.65
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 6 9.85 692.72 70.33
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.00 97.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 12 12.00 582.00 48.50
Subtotal (Total Children Is Unduplicated) 76 153.35 9491.93 61.90
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EI Services,Class #03
AUD-HA_FUP-AUDIOLOGY SERVICES 1 1.00 50.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.00 25.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 20 82.50 9487.40 115.00
OCCT-97530-OT SESSION BY LICENSED OT 68 370.08 26447.59 71.46
OCCT-97530HM-OT SESSION BY OT ASST 2 7.50 407.40 54.32
PHY-97110-PT SESSION BY LICENSED PT 30 101.68 6919.82 68.05
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 73 242.62 16473.97 67.90
Subtotal (Total Children Is Unduplicated) 137 806.38 59811.18 74.17
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Total 1026.23 71896.61 70.06
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Number of Children (Unduplicated) With at Least One Service 217
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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 16 16.25 4306.60 2508.82
D 0 0.00 0.00 0.00
S 1 1.00 235.80 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
587 1008.98 67354.21 0.00
Other 0 0.00 0.00 0.00
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Total 604 1026.23 71896.61 2508.82