CMS/EIP Fiscal Report Center: 03
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 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 194 95.25 3524.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 469 589.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 103 131.25 4856.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 494 1182.50 43752.50 37.00
TCON-TCON-TRANSITION CONFERENCE 87 87.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 731 2085.00 52133.00 25.00
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Screening, Eval, and Assessment,Class #02
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.00 16.30 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 8 8.00 70.64 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 4 4.00 43.20 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 7 7.00 152.53 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.00 54.38 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.00 56.56 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.00 31.81 31.81
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.00 115.00 57.50
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 5.50 412.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 5.00 375.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.50 262.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 5.00 277.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 62 115.50 8662.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 55 92.50 6937.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 69 123.50 6854.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 36 61.50 4612.50 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.00 48.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 15 16.00 663.73 41.48
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 2 2.00 72.00 36.00
PSTH-97001-EVAL BY LICENSED PT, INITIAL 9 9.00 395.00 43.89
SCREEN-T1023-INTERDISCIPLINARY SCREENING 5 5.00 250.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 30 30.00 1299.38 43.31
Subtotal (Total Children Is Unduplicated) 183 501.00 31663.28 63.20
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 3.00 365.08 121.69
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 99 124.00 6150.00 49.60
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 3 2.50 62.50 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 55 71.25 3562.50 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 16 15.00 375.00 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 16 31.50 1575.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 3 1.75 43.75 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 14 22.75 1137.50 50.00
CONPP-CONPP-CONSULT, PT, PHONE 1 0.25 6.25 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 48 84.25 3500.00 41.54
CONSP-CONSP-CONSULT, SLP, PHONE 9 12.00 300.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 176 1304.00 65200.00 50.00
INTR-INTR-INTERPRETER 6 32.75 1637.00 49.98
OCCT-97530-OT SESSION BY LICENSED OT 71 415.75 25177.16 60.56
PHY-97110-PT SESSION BY LICENSED PT 52 277.75 17717.10 63.79
SENS-V5050-MED HEARING AID - ANALOG/DIGITAL 2 4.00 906.00 226.50
SENS-V5264-EARMOLD 2 4.00 72.00 18.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 124 679.25 43896.75 64.63
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 371 67680.0 33814.00 0.50
Subtotal (Total Children Is Unduplicated) 516 70765.8 205497.59 2.90
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Total 73351.75 289293.87 3.94
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Number of Children (Unduplicated) With at Least One Service 879
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Center 03
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 5456 70877.75 212341.95 212341.95
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 2880 2459.50 76711.42 76711.42
27 14.50 240.50 0.00
Other 0 0.00 0.00 0.00
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Total 8363 73351.75 289293.87 289053.37