CMS/EIP Fiscal Report Center: 06
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 522 290.25 10739.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 628 663.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 408 393.00 14541.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1755 4477.25 165620.75 36.99
TCON-TCON-TRANSITION CONFERENCE 176 190.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1772 6013.50 190901.00 31.75
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 94 94.00 830.02 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 91 91.00 982.80 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 90 90.00 1961.10 21.79
EXIT-EXIT-TRANSITION ASSESSMENT 4 4.00 200.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 9 15.50 1162.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 8.00 600.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 7.50 562.50 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 227 351.50 26362.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 158 243.00 18225.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 108 177.00 13275.00 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 15.50 1162.50 75.00
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 6 6.00 163.32 27.22
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 20 20.00 1145.40 57.27
MED-99212-OUTPATIENT VISIT, EST, 10 MINS 2 2.00 36.34 18.17
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 8 8.00 276.00 34.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 2.00 97.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 4 4.00 194.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 6 6.00 291.00 48.50
Subtotal (Total Children Is Unduplicated) 299 1145.00 67526.98 58.98
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 12 12.00 7572.46 631.04
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 26 29.00 870.00 30.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 1 0.50 7.50 15.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 8 8.75 262.50 30.00
CONIP-CONIP-CONSULT, ITDS, PHONE 2 1.25 18.75 15.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 13 10.50 311.25 29.64
CONOP-CONOP-CONSULT, OT, PHONE 4 1.00 15.00 15.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 6 6.25 187.50 30.00
CONPP-CONPP-CONSULT, PT, PHONE 4 1.25 23.75 19.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 13 13.50 375.00 27.78
CONSP-CONSP-CONSULT, SLP, PHONE 5 4.00 60.00 15.00
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 27 255.50 12762.50 49.95
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 247 1901.00 94650.00 49.79
INTR-INTR-INTERPRETER 14 67.00 3842.00 57.34
OCCT-97530-OT SESSION BY LICENSED OT 187 979.00 64034.18 65.41
OCCT-97530HM-OT SESSION BY OT ASST 19 66.50 3572.28 53.72
PHY-97110-PT SESSION BY LICENSED PT 243 1536.50 96276.75 62.66
PHY-97110HM-PT SESSION BY PT ASST 3 7.00 387.02 55.29
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 616 4122.00 273229.52 66.29
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 4.00 217.28 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 10 82.00 1077.74 13.14
TRAN-TRAN-FAMILY TRANSPORTATION 11 22.00 427.70 19.44
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 789 181430 90700.00 0.50
Subtotal (Total Children Is Unduplicated) 973 190561 650880.68 3.42
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Total 197719.00 909308.66 4.60
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Number of Children (Unduplicated) With at Least One Service 1862
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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 2623 1712.75 63350.00 83.25
P 7624 71236.75 205964.83 205964.83
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
19152 124769.50 639993.83 0.00
Other 0 0.00 0.00 0.00
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Total 29399 197719.00 909308.66 206048.08