CMS/EIP Fiscal Report Center: 01
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 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 2515 2442.25 90363.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 17 17.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 2216 2704.50 100057.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 4389 24089.8 890964.50 36.99
Subtotal (Total Children Is Unduplicated) 4404 29253.5 1081385.00 36.97
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 15 21.00 689.50 32.83
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 2 2.00 21.24 10.62
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 4 4.00 35.32 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 7 7.00 75.60 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 5 5.00 108.95 21.79
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 2 2.00 63.62 31.81
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.00 65.53 32.77
EVAL-EVAL-DEVELOPMENTAL EVALUATION 23 38.75 1937.50 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 87 137.00 6850.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 96 145.50 10845.00 74.54
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 4.50 318.75 70.83
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 14 23.50 1743.75 74.20
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 93 167.50 12562.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 139 200.00 11059.75 55.30
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 964 1371.50 101974.20 74.35
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 67 83.50 6262.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 213 361.50 26917.50 74.46
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1091 1558.50 86179.75 55.30
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 502 771.00 57684.10 74.82
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 30 32.00 1429.74 44.68
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 59 66.00 3691.65 55.93
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 60 68.00 3010.84 44.28
PSTH-97001-EVAL BY LICENSED PT, INITIAL 41 42.00 2474.70 58.92
SPCH-92506-SPEECH EVAL BY LICENSED SLP 207 232.00 12163.92 52.43
Subtotal (Total Children Is Unduplicated) 2109 5345.75 348165.91 65.13
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 63 189.75 50949.38 268.51
AUD-HA_FUP-AUDIOLOGY SERVICES 4 7.00 203.64 29.09
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 142 188.25 9157.50 48.65
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 25 8.75 218.75 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 40 47.00 2350.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 27 28.50 712.50 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 2 4.50 225.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 5 5.00 125.00 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 5 4.75 237.50 50.00
CONPP-CONPP-CONSULT, PT, PHONE 10 8.25 206.25 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 66 105.00 5250.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 17 11.00 275.00 25.00
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 5 9.00 270.00 30.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 79 2089.25 24845.00 11.89
EIIF-90812-INDIVIDUAL PSYCHOTHERAPY, 45-50 MINUTES 1 5.00 271.55 54.31
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 12 132.00 6600.00 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 101 2661.50 133075.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 614 7089.00 350470.88 49.44
HERN-EIIF_NM-EI HEARING SERVICES AFTER SHINE NONMED 5 36.00 1800.00 50.00
INTR-INTR-INTERPRETER 40 902.25 18898.00 20.95
OCCT-97530-OT SESSION BY LICENSED OT 214 2712.50 209435.28 77.21
OCCT-97530HM-OT SESSION BY OT ASST 13 157.25 8615.12 54.79
PHY-97110-PT SESSION BY LICENSED PT 309 4325.75 293453.94 67.84
PHY-97110HM-PT SESSION BY PT ASST 21 185.75 10096.66 54.36
RSPT-RSPT-RESPITE 1 160.50 1294.00 8.06
SENS-V5014-HEARING AID REPAIR BY MANUFACTURER 1 1.00 114.00 114.00
SENS-V5264-EARMOLD 3 4.00 74.88 18.72
SHIN-EIIF_NM-INITIAL SHINE SERVICES, IND NONMED 2 25.00 1250.00 50.00
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 5.00 250.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1143 16512.4 1103871.79 66.85
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 4 10.00 543.20 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 37 111.00 1605.14 14.46
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1739 884578 452506.91 0.51
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 31 471.00 23550.00 50.00
Subtotal (Total Children Is Unduplicated) 2051 922791 2712801.87 2.94
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Total 957390.21 4142352.78 4.33
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Number of Children (Unduplicated) With at Least One Service 4415
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Center 01
Flag Claims Units Chgs Paid
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R 25 16.25 601.25 0.00
U 0 0.00 0.00 0.00
B 3512 2413.50 103633.50 9.25
P 31479 790441.41 1999018.86 1999042.21
D 1933 2599.25 77406.45 568.20
S 2454 6165.50 72460.07 2310.19
H 114 147.50 9315.13 0.00
T 4890 103856.50 247030.81 211575.56
34014 38810.55 1367263.95 2237.97
Other 9214 12939.75 265622.76 407.28
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Total 87635 957390.21 4142352.78 2216150.66