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: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 1421 6724.75 248808.50 37.00
TCON-TCON-TRANSITION CONFERENCE 481 484.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 2001 10902.5 292200.25 26.80
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Screening, Eval, and Assessment,Class #02
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 7 7.00 114.10 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 30 32.00 273.56 8.55
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 22 23.00 246.30 10.71
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 26 29.00 657.00 22.66
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 4 4.00 211.86 52.97
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 7 7.00 196.87 28.12
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 17 18.50 925.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 17 28.50 2137.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 29 47.50 3562.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 8 12.00 900.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 25 41.00 3075.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 23 38.50 2136.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 257 433.50 32512.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 428 674.00 50550.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 116 188.50 14137.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 368 617.50 34271.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 348 557.00 41700.00 74.87
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 204 205.00 10250.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 157 181.00 7956.64 43.96
Subtotal (Total Children Is Unduplicated) 1128 3306.50 212967.87 64.41
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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 363 5936.50 289957.00 48.84
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 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 730 287813 141453.00 0.49
Subtotal (Total Children Is Unduplicated) 984 302719 945717.21 3.12
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Total 316927.75 1450885.33 4.58
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Number of Children (Unduplicated) With at Least One Service 2139
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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 25010 279663.00 896300.73 896300.73
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 16123 13634.50 477569.03 480584.15
2033 23625.25 76900.15 0.00
Other 3 3.00 41.42 0.00
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Total 43170 316927.75 1450885.33 1376884.88