CMS/EIP Fiscal Report Center: 54
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 276 116.75 4319.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 207 211.00 262.50 1.24
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 505 584.25 21534.00 36.86
TCM-T1017TL-TARGETED CASE MANAGEMENT 1269 3867.75 141182.75 36.50
Subtotal (Total Children Is Unduplicated) 1277 4779.75 167299.00 35.00
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.00 10.62 10.62
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.00 16.30 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 21 21.00 185.43 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 40 42.00 453.60 10.80
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 10 10.00 84.40 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 33 34.00 740.86 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 3 3.00 163.14 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 10 10.00 282.80 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 12 12.00 381.72 31.81
EVAL-EVAL-DEVELOPMENTAL EVALUATION 2 1.25 62.50 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 16 19.50 1462.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 14 15.00 1312.50 87.50
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 2.00 150.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 14 19.00 1762.50 92.76
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 13 16.00 888.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 58 74.50 5775.00 77.52
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 100 115.50 9150.00 79.22
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 17 19.50 1462.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 112 140.00 7770.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 111 135.50 10762.50 79.43
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 5 5.00 242.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 20 26.00 1475.90 56.77
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 5 5.00 242.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 10 10.00 485.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 46 44.00 2134.00 48.50
Subtotal (Total Children Is Unduplicated) 371 781.75 47456.77 60.71
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
AUD-HA_FUP-AUDIOLOGY SERVICES 1 1.00 50.00 50.00
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 5 4.75 237.50 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 41 35.25 1762.50 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 2 1.75 43.75 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 34 33.75 1687.50 50.00
CONOP-CONOP-CONSULT, OT, PHONE 2 0.50 12.50 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 12 7.25 362.50 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 52 44.25 2212.50 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 2 1.50 37.50 25.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 7 127.00 6350.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 332 2394.25 125024.90 52.22
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 4 4.00 200.00 50.00
INTR-INTR-INTERPRETER 23 101.00 5050.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 198 1223.82 84389.34 68.96
OCCT-97530HM-OT SESSION BY OT ASST 13 63.50 3449.32 54.32
PHY-97110-PT SESSION BY LICENSED PT 107 458.10 31004.74 67.68
PHY-97110HM-PT SESSION BY PT ASST 1 1.00 54.32 54.32
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 5 8.00 400.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 259 1268.35 86088.84 67.87
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 597 154888 132050.05 0.85
Subtotal (Total Children Is Unduplicated) 775 160667 480467.76 2.99
----------------------------------------------------------------------------------------------------------------
Total 166228.52 695223.53 4.18
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1335
----------------------------------------------------------------------------------------------------------------
Center 54
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 2253 1561.50 59779.00 0.00
P 3443 132058.77 316076.52 314176.24
D 0 0.00 0.00 0.00
S 2 99.00 471.60 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
6202 32509.25 318896.41 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 11900 166228.52 695223.53 314176.24