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: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 302 122.25 4514.00 36.92
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 273 277.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 598 676.25 25012.00 36.99
TCM-T1017TL-TARGETED CASE MANAGEMENT 651 1882.25 69125.25 36.72
TCON-TCON-TRANSITION CONFERENCE 1 1.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1063 2958.75 98651.25 33.34
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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 6 6.50 487.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 10 10.00 750.00 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 4 4.00 300.00 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 21 24.50 1837.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 66 68.01 5100.00 74.99
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 3.00 225.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 43 62.00 3441.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 53 63.01 4725.00 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 42 40.57 1966.47 48.47
Subtotal (Total Children Is Unduplicated) 231 385.85 21791.43 56.48
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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 704 172333 146573.75 0.85
Subtotal (Total Children Is Unduplicated) 781 175617 342138.52 1.95
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Total 178961.89 462581.20 2.58
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Number of Children (Unduplicated) With at Least One Service 1236
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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 3064 146881.89 323335.85 323335.85
D 19 13.25 490.25 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
5067 32066.75 138755.10 0.00
Other 0 0.00 0.00 0.00
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Total 8150 178961.89 462581.20 323335.85