CMS/EIP Fiscal Report Center: 05
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/17/2009 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 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 390 1325.25 48997.25 36.97
Subtotal (Total Children Is Unduplicated) 649 2040.75 64740.75 31.72
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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 1 1.00 55.50 55.50
EXIT-EXIT-TRANSITION ASSESSMENT 9 16.50 825.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.00 225.00 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 3.50 262.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.00 111.00 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 9 11.47 750.54 65.44
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.00 75.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 8.00 600.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 38 62.00 3441.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 12.50 937.50 75.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 1 1.00 72.78 72.78
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 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 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 87 147.97 8614.33 58.22
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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 1 1.00 25.00 25.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 86 523.17 14991.15 28.65
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 180 996.95 49774.37 49.93
INTR-INTR-INTERPRETER 6 29.25 1462.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 22 72.25 3377.14 46.74
PHY-97110-PT SESSION BY LICENSED PT 16 55.27 3445.77 62.34
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 57 182.19 11725.42 64.36
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 5 9.50 516.04 54.32
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) 429 86592.3 142961.90 1.65
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Total 88781.05 216316.98 2.44
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Number of Children (Unduplicated) With at Least One Service 713
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Center 05
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 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
3642 4256.02 68882.14 0.00
Other 0 0.00 0.00 0.00
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Total 6670 88781.05 216316.98 147434.84