CMS/EIP Fiscal Report Center: 51
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/16/2009 Page: 1
Payclass Filters:GR
Eligibility Filter:Not Part C
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 102 88.50 3274.50 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 149 253.00 9361.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 98 569.00 20988.25 36.89
Subtotal (Total Children Is Unduplicated) 176 910.50 33623.75 36.93
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.00 8.83 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.00 10.80 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.00 21.79 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.00 27.19 27.19
EVAL-EVAL-DEVELOPMENTAL EVALUATION 10 10.00 500.00 50.00
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 1 1.00 55.50 55.50
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.00 75.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 2.00 150.00 75.00
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 3 4.00 225.00 56.25
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 58 59.50 4350.00 73.11
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 16 16.50 1200.00 72.73
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 10.50 695.45 66.23
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.50 75.00 50.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 50 52.00 3750.00 72.12
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 3 3.00 218.34 72.78
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.00 97.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 2 2.00 97.00 48.50
Subtotal (Total Children Is Unduplicated) 104 169.00 11556.90 68.38
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EI Services,Class #03
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 114 7351.00 4538.00 0.62
Subtotal (Total Children Is Unduplicated) 114 7351.00 4538.00 0.62
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Total 8430.50 49718.65 5.90
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Number of Children (Unduplicated) With at Least One Service 180
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Center 51
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 314 7411.00 14155.06 14155.06
D 13 11.50 425.50 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
1244 1008.00 35138.09 0.00
Other 0 0.00 0.00 0.00
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Total 1571 8430.50 49718.65 14155.06