CMS/EIP Fiscal Report Center: 51
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 414 281.50 10406.25 36.97
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 362 488.50 18074.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 365 1452.00 53724.00 37.00
Subtotal (Total Children Is Unduplicated) 710 2222.00 82204.75 37.00
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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 1 2.00 75.00 37.50
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.00 75.00 37.50
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 34 38.50 2550.00 66.23
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 12 14.00 851.50 60.82
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 4.50 300.00 66.67
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 45 49.50 3350.00 67.68
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 4 4.00 162.00 40.50
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.00 57.27 57.27
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 3.00 145.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 4 4.00 194.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 10 11.00 533.50 48.50
VISF-VISF-VISION EVALUATION FUNCTIONAL 3 12.00 840.00 70.00
Subtotal (Total Children Is Unduplicated) 89 177.50 10851.19 61.13
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 7 30.00 3211.23 107.04
AUD-92630-AUD REHAB PRELING HEARING LOSS 1 2.00 137.72 68.86
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 19 22.50 771.50 34.29
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
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 4 207.50 10375.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 80 625.50 23912.50 38.23
OCCT-97530-OT SESSION BY LICENSED OT 34 393.75 13788.79 35.02
PHY-97110-PT SESSION BY LICENSED PT 30 205.25 12853.23 62.62
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 110 877.50 45997.98 52.42
SPL-92508-GROUP SPL SESSION PER CHILD 7 30.00 396.00 13.20
TRAN-TRAN-FAMILY TRANSPORTATION 1 96.00 48.00 0.50
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 410 111237 50197.50 0.45
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 1 9.00 630.00 70.00
Subtotal (Total Children Is Unduplicated) 448 113790 162513.20 1.43
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Total 116189.00 255569.14 2.20
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Number of Children (Unduplicated) With at Least One Service 786
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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 1989 112615.75 160633.59 160633.59
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
3725 3559.50 94419.80 5.00
Other 0 0.00 0.00 0.00
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Total 5738 116189.00 255569.14 160638.59