CMS/EIP Fiscal Report Center: 03
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 804 512.25 18953.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 1212 2521.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 497 660.50 24438.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 2250 11687.5 432430.25 37.00
TCON-TCON-TRANSITION CONFERENCE 481 484.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 2283 15865.3 475822.00 29.99
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 4 5.00 54.73 10.95
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 14 14.00 224.68 16.05
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 244 256.00 2203.78 8.61
AUDE-92557-COMP AUDIO THRESHOLD EVAL/SPCH RECOG 1 1.00 27.10 27.10
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 126 136.00 1453.68 10.69
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 239 252.00 5271.88 20.92
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 11 11.00 581.20 52.84
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 29 29.00 812.49 28.02
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 3 3.00 95.43 31.81
AUDE-V5090-DISPENSING FEE PER HEARING AID 5 8.00 805.00 100.63
EVAL-EVAL-DEVELOPMENTAL EVALUATION 17 18.50 925.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 18 30.00 2250.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 35 57.00 4275.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 9 14.00 1050.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 29 47.50 3562.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 28 47.00 2608.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 294 494.50 37087.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 475 751.50 56362.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 132 214.00 16050.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 429 716.00 39738.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 381 609.50 45637.50 74.88
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 14 14.00 634.47 45.32
PSTH-97001-EVAL BY LICENSED PT, INITIAL 38 42.00 1634.13 38.91
SCREEN-T1023-INTERDISCIPLINARY SCREENING 277 278.00 13900.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 157 181.00 7956.64 43.96
Subtotal (Total Children Is Unduplicated) 1324 4327.50 249315.03 57.61
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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 327 583.75 26120.00 44.75
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 27 28.50 712.50 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 119 374.25 13787.50 36.84
CONIP-CONIP-CONSULT, ITDS, PHONE 46 107.00 1433.25 13.39
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 123 294.50 14012.50 47.58
CONSP-CONSP-CONSULT, SLP, PHONE 21 41.00 1025.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 373 6038.00 295032.00 48.86
INTR-INTR-INTERPRETER 30 261.50 14709.50 56.25
OCCT-97530-OT SESSION BY LICENSED OT 162 1992.75 114737.22 57.58
PHY-97110-PT SESSION BY LICENSED PT 114 1416.50 85177.99 60.13
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 730 287813 141453.00 0.49
Subtotal (Total Children Is Unduplicated) 986 302844 952404.36 3.14
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Total 323036.75 1677541.39 5.19
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Number of Children (Unduplicated) With at Least One Service 2335
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Center 03
Flag Claims Units Chgs Paid
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R 21 14.25 527.25 0.00
U 0 0.00 0.00 0.00
B 809 720.75 31768.01 83.25
P 31098 284382.25 1079583.04 1079339.54
D 0 0.00 0.00 0.00
S 2 1.00 37.00 0.00
H 1 0.25 9.25 9.25
T 16123 13634.50 477569.03 480584.15
2089 23671.75 78677.65 0.00
Other 613 612.00 9370.16 18.50
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Total 50756 323036.75 1677541.39 1560034.69