CMS/EIP Fiscal Report Center: 06
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 522 289.75 10720.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 625 660.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 407 391.75 14494.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1014 2588.50 95758.75 36.99
TCON-TCON-TRANSITION CONFERENCE 176 190.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1453 4120.00 120974.25 29.36
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 12 12.00 105.96 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 12 12.00 129.60 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 12 12.00 261.48 21.79
EXIT-EXIT-TRANSITION ASSESSMENT 3 3.00 150.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.00 150.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.00 150.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 16 25.00 1875.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 11 17.00 1275.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 13.00 975.00 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.00 225.00 75.00
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 3 3.00 103.50 34.50
Subtotal (Total Children Is Unduplicated) 29 104.00 5400.54 51.93
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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 25 28.00 840.00 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 26 251.00 12537.50 49.95
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 164 1244.00 61800.00 49.68
INTR-INTR-INTERPRETER 14 67.00 3842.00 57.34
OCCT-97530-OT SESSION BY LICENSED OT 106 472.50 29652.96 62.76
OCCT-97530HM-OT SESSION BY OT ASST 8 31.00 1643.92 53.03
PHY-97110-PT SESSION BY LICENSED PT 118 673.75 37713.28 55.98
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 430 2792.75 183000.03 65.53
SPL-92508-GROUP SPL SESSION PER CHILD 9 78.50 1031.54 13.14
TRAN-TRAN-FAMILY TRANSPORTATION 11 22.00 427.70 19.44
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 788 181326 90648.00 0.50
Subtotal (Total Children Is Unduplicated) 923 187046 431970.64 2.31
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Total 191269.50 558345.43 2.92
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Number of Children (Unduplicated) With at Least One Service 1622
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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 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
13622 120032.75 352380.60 0.00
Other 0 0.00 0.00 0.00
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Total 21246 191269.50 558345.43 205964.83