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: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 561 1394.00 51578.00 37.00
TCON-TCON-TRANSITION CONFERENCE 87 87.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 809 2308.25 60356.25 26.15
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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) 10 19.00 167.77 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 6 15.00 162.00 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 8 8.00 174.32 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 2 2.00 108.76 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 3.00 84.84 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 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 4 6.50 360.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 85 155.50 11662.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 81 135.50 10162.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 103 182.50 10128.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 54 89.00 6675.00 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 15 15.00 750.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 30 30.00 1299.38 43.31
Subtotal (Total Children Is Unduplicated) 252 724.50 44854.41 61.91
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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 176 1304.00 65200.00 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) 522 70893.8 206155.59 2.91
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Total 73926.50 311366.25 4.21
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Number of Children (Unduplicated) With at Least One Service 977
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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 5478 71029.75 214604.95 214604.95
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 3239 2882.25 96520.80 96520.80
27 14.50 240.50 0.00
Other 0 0.00 0.00 0.00
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Total 8744 73926.50 311366.25 311125.75