CMS/EIP Fiscal Report Center: 09
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Payclass Filters:TPIN
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
TCM-T1017TL-TARGETED CASE MANAGEMENT 3 2.75 101.75 37.00
Subtotal (Total Children Is Unduplicated) 3 2.75 101.75 37.00
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Screening, Eval, and Assessment,Class #02
AUDE-V5090-DISPENSING FEE PER HEARING AID 2 4.00 478.40 119.60
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 48 70.50 5287.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 2.00 150.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 16 18.00 1350.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 28 48.50 3637.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 7 8.00 444.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 134 163.00 12225.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 8.50 637.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 90 109.00 8175.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 55 70.50 3912.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 50 57.00 4275.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 5 5.00 242.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 2.00 97.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.00 97.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 1.00 50.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 9 9.00 436.50 48.50
Subtotal (Total Children Is Unduplicated) 206 578.00 41495.65 71.79
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.50 75.00 50.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 2 2.00 100.00 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 2 2.00 100.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 6 6.00 300.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 138 647.75 43935.33 67.83
OCCT-97530HM-OT SESSION BY OT ASST 5 14.00 760.48 54.32
PHY-97110-PT SESSION BY LICENSED PT 128 542.50 36818.12 67.87
PHY-97110HM-PT SESSION BY PT ASST 4 30.00 1629.60 54.32
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 1 2.00 1000.00 500.00
SENS-V5050-MED HEARING AID - ANALOG/DIGITAL 1 2.00 474.24 237.12
SENS-V5264-EARMOLD 2 6.00 112.32 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 219 1049.25 71121.27 67.78
SPL-92508-GROUP SPL SESSION PER CHILD 1 0.50 6.60 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 1.00 0.50 0.50
Subtotal (Total Children Is Unduplicated) 343 2306.50 156433.46 67.82
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Total 2887.25 198030.86 68.59
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Number of Children (Unduplicated) With at Least One Service 503
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Center 09
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 27 37.50 2526.12 5306.71
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 0 0.00 0.00 0.00
1778 2849.75 195504.74 1938.00
Other 0 0.00 0.00 0.00
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Total 1805 2887.25 198030.86 7244.71