CMS/EIP Fiscal Report Center: 05
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/17/2009 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 271 105.75 3912.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 272 290.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 347 319.75 11830.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 752 2552.25 94396.25 36.99
Subtotal (Total Children Is Unduplicated) 757 3267.75 110139.75 33.71
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.00 8.83 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.00 10.80 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.00 21.79 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.00 28.28 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.00 31.81 31.81
EVAL-EVAL-DEVELOPMENTAL EVALUATION 9 9.00 455.50 50.61
EXIT-EXIT-TRANSITION ASSESSMENT 9 16.50 825.00 50.00
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 1 1.00 75.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 8 8.50 637.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 7 7.50 562.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.50 194.25 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 16 16.00 888.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 39 50.47 3675.54 72.83
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 9.00 675.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 32 41.00 3075.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 52 81.50 4523.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 18 23.50 1762.50 75.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 11 11.00 800.58 72.78
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 9 9.00 451.35 50.15
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 8 8.00 388.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 6 6.00 291.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 10 10.00 485.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 6 6.00 291.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 3 3.00 150.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 8 8.00 388.00 48.50
Subtotal (Total Children Is Unduplicated) 176 338.47 21070.48 62.25
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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 52 46.00 2300.00 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 1 0.50 12.50 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 195 167.25 8362.50 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 9 3.00 75.00 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 25 12.75 637.50 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 40 30.50 1525.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 70 37.75 1887.50 50.00
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 3 4.00 100.00 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 7 18.25 456.25 25.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 90 799.67 28816.15 36.04
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 274 1545.95 77224.37 49.95
INTR-INTR-INTERPRETER 6 29.25 1462.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 97 332.75 21059.88 63.29
OCCT-97530HM-OT SESSION BY OT ASST 4 10.00 543.20 54.32
PHY-97110-PT SESSION BY LICENSED PT 138 471.52 31700.82 67.23
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 177 653.44 43713.87 66.90
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 18 44.50 2417.24 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 2 3.00 39.60 13.20
TRAN-TRAN-FAMILY TRANSPORTATION 1 26.00 497.51 19.14
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 394 84394.0 42197.00 0.50
Subtotal (Total Children Is Unduplicated) 463 88631.1 265078.39 2.99
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Total 92237.30 396288.62 4.30
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Number of Children (Unduplicated) With at Least One Service 772
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Center 05
Flag Claims Units Chgs Paid
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R 20 20.00 1364.20 0.00
U 0 0.00 0.00 0.00
B 2209 1161.75 43079.75 0.00
P 3028 84525.03 147434.84 147434.84
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
6502 6530.52 204409.83 0.00
Other 0 0.00 0.00 0.00
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Total 11759 92237.30 396288.62 147434.84