CMS/EIP Fiscal Report Center: 03
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 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 206 101.75 3764.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 470 590.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 111 135.50 5013.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 903 2368.25 87625.25 37.00
TCON-TCON-TRANSITION CONFERENCE 87 87.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 936 3282.50 96403.50 29.37
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Screening, Eval, and Assessment,Class #02
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 2 11.00 179.30 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 64 74.00 653.42 8.83
AUDE-92557-COMP AUDIO THRESHOLD EVAL/SPCH RECOG 1 1.00 27.10 27.10
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 26 36.00 388.80 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 62 63.00 1372.77 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 2 2.00 108.76 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 8 8.00 226.24 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 2 2.00 63.62 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 6 9.50 712.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 6.50 487.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 8.50 471.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 99 177.50 13312.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 97 162.00 12150.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 115 201.50 11183.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 66 107.00 8025.00 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 17 17.00 850.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 30 30.00 1299.38 43.31
Subtotal (Total Children Is Unduplicated) 306 952.00 53218.62 55.90
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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 100 125.00 6200.00 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 178 1307.50 65375.00 50.00
INTR-INTR-INTERPRETER 10 43.75 2187.00 49.99
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 376 67796.0 33872.00 0.50
Subtotal (Total Children Is Unduplicated) 523 70897.3 206330.59 2.91
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Total 75131.75 355952.71 4.74
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Number of Children (Unduplicated) With at Least One Service 1071
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Center 03
Flag Claims Units Chgs Paid
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R 4 3.00 111.00 0.00
U 0 0.00 0.00 0.00
B 224 226.75 10882.75 0.00
P 6478 71832.00 244364.20 244306.70
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 3239 2882.25 96520.80 96520.80
63 49.75 1962.75 0.00
Other 138 138.00 2111.21 0.00
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Total 10146 75131.75 355952.71 340827.50