CMS/EIP Fiscal Report Center: 02
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Payclass Filters:GR
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 169 65.00 2405.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 104 105.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 164 248.75 9203.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 177 382.75 14097.00 36.83
TCON-TCON-TRANSITION CONFERENCE 14 14.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 372 815.50 25705.75 31.52
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Screening, Eval, and Assessment,Class #02
AUDE-92557-COMP AUDIO THRESHOLD EVAL/SPCH RECOG 2 4.00 90.00 22.50
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.00 10.80 10.80
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.00 54.38 27.19
AUDE-V5090-DISPENSING FEE PER HEARING AID 3 6.00 225.85 37.64
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 2.00 100.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 6 8.00 400.00 50.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 28 45.50 3412.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 11 16.50 1237.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 10 14.00 980.95 70.07
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 25 37.50 2053.50 54.76
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.00 225.00 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 55 141.50 8887.48 62.81
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.00 347.09 173.55
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 4 4.25 212.50 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 10 8.00 400.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 1 0.25 6.25 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 8 3.25 162.50 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 9 6.75 337.50 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 2 0.50 12.50 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 56 332.00 16600.00 50.00
INTR-INTR-INTERPRETER 2 8.50 360.00 42.35
OCCT-97530-OT SESSION BY LICENSED OT 23 136.75 8878.64 64.93
PHY-97110-PT SESSION BY LICENSED PT 11 34.25 1881.60 54.94
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 58 438.25 29598.41 67.54
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 227 60050.0 29998.86 0.50
Subtotal (Total Children Is Unduplicated) 249 61024.8 88795.85 1.46
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Total 61981.75 123389.08 1.99
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Number of Children (Unduplicated) With at Least One Service 487
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Center 02
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 0 0.00 0.00 0.00
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 736 24871.00 36931.33 36931.33
2116 37110.75 86457.75 0.00
Other 0 0.00 0.00 0.00
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Total 2852 61981.75 123389.08 36931.33