CMS/EIP Fiscal Report Center: 03
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Payclass Filters:GR
Eligibility Filter:Part C (excluding not eligible)
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 728 474.00 17538.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 1200 2508.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 467 634.00 23458.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1144 5826.00 215562.00 37.00
TCON-TCON-TRANSITION CONFERENCE 481 484.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1675 9926.00 256558.00 25.85
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Screening, Eval, and Assessment,Class #02
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 6 6.00 97.80 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 27 29.00 247.97 8.55
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 19 20.00 214.32 10.72
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 24 27.00 618.21 22.90
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 3 3.00 157.48 52.49
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 6 6.00 168.59 28.10
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 2 2.00 63.62 31.81
AUDE-V5090-DISPENSING FEE PER HEARING AID 5 8.00 805.00 100.63
EVAL-EVAL-DEVELOPMENTAL EVALUATION 16 16.50 825.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 16 27.00 2025.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 21 37.00 2775.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 7.50 562.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 18 32.00 2400.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 17 29.00 1609.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 195 338.00 25350.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 281 454.00 34050.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 86 145.50 10912.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 256 445.00 24697.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 232 385.50 28837.50 74.81
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 27 28.00 1222.02 43.64
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 64 70.00 2891.30 41.30
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 13 13.00 585.97 45.07
PSTH-97001-EVAL BY LICENSED PT, INITIAL 37 41.00 1585.63 38.67
SCREEN-T1023-INTERDISCIPLINARY SCREENING 104 105.00 5250.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 157 181.00 7956.64 43.96
Subtotal (Total Children Is Unduplicated) 790 2456.00 155909.05 63.48
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 6 8.00 4661.45 582.68
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 324 577.75 25820.00 44.69
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 27 28.50 712.50 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 118 372.25 13687.50 36.77
CONIP-CONIP-CONSULT, ITDS, PHONE 45 106.00 1408.25 13.29
CONOF-CONOF-CONSULT, OT, FACE TO FACE 33 99.00 4950.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 9 8.50 212.50 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 34 95.00 4687.50 49.34
CONPP-CONPP-CONSULT, PT, PHONE 5 2.25 56.25 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 121 291.50 13862.50 47.56
CONSP-CONSP-CONSULT, SLP, PHONE 20 40.00 1000.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 363 5936.50 289957.00 48.84
INTR-INTR-INTERPRETER 23 240.25 13577.00 56.51
OCCT-97530-OT SESSION BY LICENSED OT 162 1992.75 114737.22 57.58
PHY-97110-PT SESSION BY LICENSED PT 112 1392.75 83565.84 60.00
SENS-V5014-HEARING AID REPAIR BY MANUFACTURER 1 2.00 228.00 114.00
SENS-V5050-MED HEARING AID - ANALOG/DIGITAL 4 8.00 1818.00 227.25
SENS-V5264-EARMOLD 6 12.00 212.00 17.67
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 332 3658.50 227378.20 62.15
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 722 286853 140973.00 0.49
Subtotal (Total Children Is Unduplicated) 972 301725 943504.71 3.13
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Total 314106.50 1355971.76 4.32
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Number of Children (Unduplicated) With at Least One Service 1737
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Center 03
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 1 2.00 74.00 0.00
P 24944 278657.00 891879.48 891879.48
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 14283 11859.75 388196.96 390897.96
2009 23584.75 75779.90 0.00
Other 3 3.00 41.42 0.00
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Total 41240 314106.50 1355971.76 1282777.44