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: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 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) 578 603.00 5216.49 8.65
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 538 560.00 6002.22 10.72
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 540 561.00 11692.50 20.84
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 47 47.00 1323.71 28.16
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 1.00 30.00 30.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 13 22.00 1650.00 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 8 15.00 1125.00 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 469 732.00 54900.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 363 560.00 42000.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 188 305.50 22912.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 6.00 333.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 21 34.50 2587.50 75.00
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 15 15.00 415.09 27.67
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 67 67.00 4008.93 59.83
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) 809 3604.50 158303.10 43.92
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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 181 1540.50 104704.90 67.97
PHY-97110HM-PT SESSION BY PT ASST 13 43.75 2383.28 54.47
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 341 2128.00 144114.24 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) 536 5301.25 348682.25 65.77
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Total 8933.25 507965.85 56.86
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Number of Children (Unduplicated) With at Least One Service 1059
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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
9936 8933.25 507965.85 0.00
Other 0 0.00 0.00 0.00
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Total 9936 8933.25 507965.85 0.00