CMS/EIP Fiscal Report Center: 51
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 414 281.50 10406.25 36.97
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 362 488.50 18074.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 850 3623.50 134001.50 36.98
Subtotal (Total Children Is Unduplicated) 870 4393.50 162482.25 36.98
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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
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 2 2.00 250.00 125.00
EVAL-EVAL-DEVELOPMENTAL EVALUATION 6 6.00 300.00 50.00
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 2 2.00 105.50 52.75
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 7.00 450.00 64.29
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 7.00 450.00 64.29
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.50 75.00 50.00
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 11 15.00 822.00 54.80
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 84 96.00 6862.50 71.48
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 25 30.00 2051.50 68.38
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 8.00 562.50 70.31
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 7 9.00 491.25 54.58
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 117 134.50 9651.50 71.76
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 5 5.00 202.50 40.50
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.00 57.27 57.27
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 10 10.00 485.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 7 7.00 339.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 4 4.00 194.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 19 19.00 921.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 20 21.00 1018.50 48.50
VISF-VISF-VISION EVALUATION FUNCTIONAL 3 12.00 840.00 70.00
Subtotal (Total Children Is Unduplicated) 191 400.00 26171.44 65.43
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 10 62.00 14241.80 229.71
AUD-92630-AUD REHAB PRELING HEARING LOSS 1 2.00 137.72 68.86
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 20 23.50 821.50 34.96
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 3 52.00 150.00 2.88
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 0.25 12.50 50.00
CONPP-CONPP-CONSULT, PT, PHONE 5 1.25 31.25 25.00
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 2 12.00 881.04 73.42
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 4 207.50 10375.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 205 1481.00 66687.50 45.03
OCCT-97530-OT SESSION BY LICENSED OT 108 843.25 44233.03 52.46
OCCT-97530HM-OT SESSION BY OT ASST 13 37.75 2050.58 54.32
PHY-97110-PT SESSION BY LICENSED PT 118 677.50 44757.01 66.06
PHY-97110HM-PT SESSION BY PT ASST 20 112.50 6111.00 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 195 1400.25 81095.67 57.92
SPL-92508-GROUP SPL SESSION PER CHILD 10 33.25 438.90 13.20
TRAN-TRAN-FAMILY TRANSPORTATION 1 96.00 48.00 0.50
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 411 111553 50355.50 0.45
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 1 9.00 630.00 70.00
Subtotal (Total Children Is Unduplicated) 472 116604 323058.00 2.77
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Total 121397.50 511711.69 4.22
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Number of Children (Unduplicated) With at Least One Service 885
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Center 51
Flag Claims Units Chgs Paid
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R 2 2.00 150.00 0.00
U 0 0.00 0.00 0.00
B 3196 2251.00 84946.30 0.00
P 2017 112838.00 164967.51 164967.51
D 24 13.75 515.75 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
4810 6292.75 261132.13 5.00
Other 0 0.00 0.00 0.00
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Total 10049 121397.50 511711.69 164972.51