CMS/EIP Fiscal Report Center: 02
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 612 281.00 10350.75 36.84
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 394 489.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 659 1203.00 44344.50 36.86
TCM-T1017TL-TARGETED CASE MANAGEMENT 1256 5676.25 209326.50 36.88
TCON-TCON-TRANSITION CONFERENCE 74 74.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1275 7723.25 264021.75 34.19
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Screening, Eval, and Assessment,Class #02
AUDE-92557-COMP AUDIO THRESHOLD EVAL/SPCH RECOG 4 8.00 180.00 22.50
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.00 10.80 10.80
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 4 5.00 108.76 21.75
AUDE-V5090-DISPENSING FEE PER HEARING AID 4 7.00 340.85 48.69
EVAL-EVAL-DEVELOPMENTAL EVALUATION 8 11.00 550.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 20 28.00 1400.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.00 150.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 8.00 444.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 216 352.00 26170.00 74.35
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 140 206.00 15307.50 74.31
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 94 125.50 9193.45 73.25
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 264 406.50 22283.25 54.82
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 14 21.00 1575.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 2 2.00 97.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 10 10.00 440.50 44.05
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 21 22.00 1067.00 48.50
Subtotal (Total Children Is Unduplicated) 408 1217.00 79441.61 65.28
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 15 67.00 5203.35 77.66
AUD-HA_FUP-AUDIOLOGY SERVICES 2 5.00 155.76 31.15
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 40 35.50 1725.00 48.59
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 32 32.25 1612.50 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 3 1.25 31.25 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 42 32.75 1637.50 50.00
CONOP-CONOP-CONSULT, OT, PHONE 3 1.75 43.75 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 3 1.00 50.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 31 32.00 1600.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 8 4.25 106.25 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 110 1248.50 62425.00 50.00
INTR-INTR-INTERPRETER 16 82.75 3951.95 47.76
OCCT-97530-OT SESSION BY LICENSED OT 67 641.50 40362.67 62.92
OCCT-97530HM-OT SESSION BY OT ASST 2 13.00 112.32 8.64
PHY-97110-PT SESSION BY LICENSED PT 24 200.00 12024.37 60.12
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 1 1.00 399.00 399.00
SENS-V5264-EARMOLD 2 12.00 126.72 10.56
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 1.50 75.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 125 1829.75 123611.81 67.56
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 448 203290 101573.36 0.50
Subtotal (Total Children Is Unduplicated) 503 207533 356827.56 1.72
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Total 216473.00 700290.92 3.24
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Number of Children (Unduplicated) With at Least One Service 1282
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Center 02
Flag Claims Units Chgs Paid
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R 16 13.25 490.25 0.00
U 0 0.00 0.00 0.00
B 3874 3017.25 111323.75 0.00
P 1535 31367.75 72641.16 72641.16
D 0 0.00 0.00 0.00
S 13 21.75 1046.36 0.00
H 0 0.00 0.00 0.00
T 4246 132149.25 248484.50 248230.86
7306 49897.75 266268.90 119.88
Other 1 6.00 36.00 0.00
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Total 16991 216473.00 700290.92 320991.90