CMS/EIP Fiscal Report Center: 54
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Payclass Filters:GR
Eligibility Filter:Part C (excluding not eligible)
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 269 110.50 4079.25 36.92
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 263 267.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 486 554.50 20507.25 36.98
TCM-T1017TL-TARGETED CASE MANAGEMENT 563 1581.00 58090.00 36.74
TCON-TCON-TRANSITION CONFERENCE 1 1.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 914 2514.00 82676.50 32.89
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 4 4.00 35.32 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 21 21.00 226.80 10.80
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 9 9.00 75.96 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 25 25.00 544.75 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 14 13.16 371.76 28.25
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 2 2.00 63.62 31.81
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 1 0.60 75.00 125.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 5.50 412.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 7 7.00 525.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 11 15.50 860.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 13 14.50 1087.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 41 43.67 3275.00 74.99
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 24 36.00 1998.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 28 33.67 2525.00 74.99
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.00 48.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 5 5.00 242.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 2 2.00 97.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 5 5.00 242.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 41 39.87 1932.97 48.48
Subtotal (Total Children Is Unduplicated) 166 286.47 14864.93 51.89
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 3 2.50 125.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 65 69.25 3462.50 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 8 3.25 81.25 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 30 27.00 1350.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 4 1.25 31.25 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 6 3.00 150.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 54 57.75 2887.50 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 9 164.50 8225.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 147 1065.50 53275.00 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 4 8.00 400.00 50.00
INTR-INTR-INTERPRETER 20 120.00 6000.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 108 644.63 43739.14 67.85
PHY-97110-PT SESSION BY LICENSED PT 43 201.25 13635.79 67.76
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 144 916.41 62202.34 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 618 168102 143002.25 0.85
Subtotal (Total Children Is Unduplicated) 695 171386 338567.02 1.98
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Total 174186.76 436108.45 2.50
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Number of Children (Unduplicated) With at Least One Service 1081
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Center 54
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 2906 143858.01 315435.90 315435.90
D 16 9.75 360.75 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
4448 30319.00 120311.80 0.00
Other 0 0.00 0.00 0.00
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Total 7370 174186.76 436108.45 315435.90