CMS/EIP Fiscal Report Center: 09
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 791 733.75 27139.75 36.99
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 429 465.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 649 671.00 24771.50 36.92
TCM-T1017TL-TARGETED CASE MANAGEMENT 1570 4970.25 183633.00 36.95
TCON-TCON-TRANSITION CONFERENCE 66 69.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1644 6909.00 235544.25 34.09
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Screening, Eval, and Assessment,Class #02
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 2.00 93.60 46.80
AUDE-V5090-DISPENSING FEE PER HEARING AID 2 4.00 478.40 119.60
EVAL-EVAL-DEVELOPMENTAL EVALUATION 14 13.00 650.00 50.00
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 3 5.00 277.50 55.50
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 95 135.00 10125.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 14 22.00 1650.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 44 51.00 3825.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 46 75.00 5625.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 32 44.00 2442.00 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 10 17.00 943.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 347 463.00 34725.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 127 246.00 18450.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 215 273.00 20475.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 291 447.00 24808.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 92 111.00 8325.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 7 7.00 339.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 4 4.00 194.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 3 3.00 145.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 6 6.00 291.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 25 25.00 1250.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 16 16.00 776.00 48.50
Subtotal (Total Children Is Unduplicated) 667 1969.00 135889.50 69.01
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EI Services,Class #03
AUD-HA_FUP-AUDIOLOGY SERVICES 1 1.00 50.00 50.00
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 57 70.75 3537.50 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 1 0.50 12.50 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 13 33.50 1675.00 50.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 17 30.00 1500.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 2 0.50 12.50 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 11 27.75 1387.50 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 42 51.75 2587.50 50.00
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 9 28.00 2055.76 73.42
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 340 2544.75 123737.50 48.62
INTR-INTR-INTERPRETER 20 78.25 3912.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 360 2302.00 154531.93 67.13
OCCT-97530HM-OT SESSION BY OT ASST 13 29.50 1602.44 54.32
PHY-97110-PT SESSION BY LICENSED PT 329 1959.75 130928.46 66.81
PHY-97110HM-PT SESSION BY PT ASST 16 104.75 5690.02 54.32
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 2 4.00 2000.00 500.00
SENS-V5050-MED HEARING AID - ANALOG/DIGITAL 1 2.00 474.24 237.12
SENS-V5264-EARMOLD 3 8.00 149.76 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 648 4306.50 290232.55 67.39
SPL-92508-GROUP SPL SESSION PER CHILD 4 3.50 46.20 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 714 147948 73966.50 0.50
Subtotal (Total Children Is Unduplicated) 1105 159535 800090.36 5.02
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Total 168412.75 1171524.11 6.96
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Number of Children (Unduplicated) With at Least One Service 1958
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Center 09
Flag Claims Units Chgs Paid
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R 23 17.75 1073.55 0.00
U 0 0.00 0.00 0.00
B 570 574.00 32063.58 152.75
P 7945 88456.00 468881.22 498658.06
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 1 1.75 64.75 64.75
T 2737 68913.50 195750.15 195750.15
7876 10448.50 473644.61 3083.92
Other 2 1.25 46.25 0.00
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Total 19154 168412.75 1171524.11 697709.63