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: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 1284 912.00 33744.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 1815 2615.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1785 2025.25 74933.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 2084 11868.0 439014.00 36.99
TCON-TCON-TRANSITION CONFERENCE 651 692.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 3054 18112.3 547691.25 30.24
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 98 101.00 877.43 8.69
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 89 92.00 987.72 10.74
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 87 90.00 1894.04 21.04
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 7 7.00 196.87 28.12
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 1 1.00 50.00 50.00
EVAL-EVAL-DEVELOPMENTAL EVALUATION 217 275.00 8270.00 30.07
EXIT-EXIT-TRANSITION ASSESSMENT 3 3.00 150.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 6.00 450.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 6 9.00 675.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.50 112.50 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 144 221.50 16612.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 152 240.50 18037.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 52 86.00 6450.00 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 13 23.00 1725.00 75.00
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 2 2.00 54.44 27.22
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 10 10.00 587.02 58.70
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 3 3.00 103.50 34.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 13 13.00 540.96 41.61
PSTH-97001-EVAL BY LICENSED PT, INITIAL 3 3.00 145.00 48.33
SPCH-92506-SPEECH EVAL BY LICENSED SLP 8 8.00 368.00 46.00
Subtotal (Total Children Is Unduplicated) 548 1195.50 58287.48 48.76
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 39 46.00 18857.16 409.94
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 94 132.75 3952.50 29.77
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 3 2.50 37.50 15.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 12 19.25 577.50 30.00
CONIP-CONIP-CONSULT, ITDS, PHONE 10 6.75 101.25 15.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 32 39.75 1190.00 29.94
CONOP-CONOP-CONSULT, OT, PHONE 16 8.50 118.75 13.97
CONPF-CONPF-CONSULT, PT, FACE TO FACE 16 16.25 487.50 30.00
CONPP-CONPP-CONSULT, PT, PHONE 5 2.00 35.00 17.50
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 27 38.25 1068.75 27.94
CONSP-CONSP-CONSULT, SLP, PHONE 15 10.25 173.75 16.95
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 107 2476.25 123787.50 49.99
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 3.00 150.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 426 7526.50 369668.50 49.12
INTR-INTR-INTERPRETER 60 425.25 22832.21 53.69
OCCT-97530-OT SESSION BY LICENSED OT 318 3367.00 205477.00 61.03
OCCT-97530HM-OT SESSION BY OT ASST 43 344.25 17509.75 50.86
PHY-97110-PT SESSION BY LICENSED PT 319 3493.50 198609.71 56.85
PHY-97110HM-PT SESSION BY PT ASST 4 25.00 842.16 33.69
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 924 13414.5 867962.76 64.70
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 2 4.00 182.84 45.71
SPL-92508-GROUP SPL SESSION PER CHILD 18 191.50 2118.44 11.06
TRAN-TRAN-FAMILY TRANSPORTATION 74 507.00 3718.28 7.33
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1435 755734 377370.05 0.50
Subtotal (Total Children Is Unduplicated) 1645 787834 2216828.86 2.81
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Total 807141.75 2822807.59 3.50
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Number of Children (Unduplicated) With at Least One Service 3106
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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 63300 668309.00 1975349.27 1975349.27
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
35170 138832.75 847458.32 4033.00
Other 0 0.00 0.00 0.00
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Total 98470 807141.75 2822807.59 1979382.27