CMS/EIP Fiscal Report Center: 06
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Payclass Filters:TPIN
Eligibility Filter:Part C (excluding not eligible)
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 3 1.50 55.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1.00 0.00 0.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 12 25.00 925.00 37.00
Subtotal (Total Children Is Unduplicated) 13 27.50 980.50 35.65
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 497 522.00 4520.16 8.66
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 459 481.00 5157.42 10.72
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 459 480.00 10023.31 20.88
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 41 41.00 1154.03 28.15
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 1.00 30.00 30.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 10 18.00 1350.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 10 18.00 1350.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 7 14.00 1050.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.50 112.50 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 400 638.00 47850.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 309 488.00 36600.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 167 274.50 20587.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 3.00 166.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 18 30.00 2250.00 75.00
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 15 15.00 415.09 27.67
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 63 63.00 3765.53 59.77
MED-99212-OUTPATIENT VISIT, EST, 10 MINS 1 1.00 18.17 18.17
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 5 5.00 181.11 36.22
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 10 10.00 485.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 22 24.00 1164.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 16 16.00 795.38 49.71
Subtotal (Total Children Is Unduplicated) 702 3144.00 139025.70 44.22
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 2 2.00 60.00 30.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 0.50 25.00 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 2 1.50 65.00 43.33
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.00 25.00 25.00
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 4.50 225.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 17 77.00 3850.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 169 1312.75 89109.47 67.88
OCCT-97530HM-OT SESSION BY OT ASST 19 59.25 3218.46 54.32
PHY-97110-PT SESSION BY LICENSED PT 180 1539.00 104603.08 67.97
PHY-97110HM-PT SESSION BY PT ASST 13 43.75 2383.28 54.47
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 340 2127.00 144046.36 67.72
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 3 10.00 543.20 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 10 23.50 310.20 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 3 97.00 48.50 0.50
Subtotal (Total Children Is Unduplicated) 534 5298.75 348512.55 65.77
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Total 8470.25 488518.75 57.67
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Number of Children (Unduplicated) With at Least One Service 951
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Center 06
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 0 0.00 0.00 0.00
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
9526 8470.25 488518.75 0.00
Other 0 0.00 0.00 0.00
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Total 9526 8470.25 488518.75 0.00