CMS/EIP Fiscal Report Center: 03
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 279 129.25 4782.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 458 573.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 142 164.00 6068.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 657 1516.00 56092.00 37.00
TCON-TCON-TRANSITION CONFERENCE 136 136.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 942 2518.25 66942.25 26.58
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Screening, Eval, and Assessment,Class #02
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 2 2.00 32.60 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 6 6.00 52.98 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 5 5.00 54.00 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 5 5.00 108.95 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.00 54.38 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.00 56.56 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.00 31.81 31.81
AUDE-V5090-DISPENSING FEE PER HEARING AID 3 5.00 575.00 115.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 10.50 787.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.00 150.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.00 150.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.00 150.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 8.50 471.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 67 121.50 9112.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 10 18.50 1387.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 6.00 450.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 68 123.00 6826.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 14.00 1050.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 7 7.00 322.90 46.13
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 9 9.00 391.50 43.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 4 4.00 146.95 36.74
SCREEN-T1023-INTERDISCIPLINARY SCREENING 188 188.00 9400.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 31 32.00 1453.36 45.42
Subtotal (Total Children Is Unduplicated) 282 576.00 33265.24 57.75
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.00 3095.00 1547.50
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 111 199.00 7025.00 35.30
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 6 7.00 175.00 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 61 201.75 5162.50 25.59
CONIP-CONIP-CONSULT, ITDS, PHONE 5 4.50 112.50 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 16 30.50 1525.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 1 0.50 12.50 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 15 23.25 1100.00 47.31
CONPP-CONPP-CONSULT, PT, PHONE 1 0.50 12.50 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 57 109.00 5450.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 4 5.00 125.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 154 1206.00 60300.00 50.00
INTR-INTR-INTERPRETER 7 58.00 3480.00 60.00
OCCT-97530-OT SESSION BY LICENSED OT 76 452.00 27744.14 61.38
PHY-97110-PT SESSION BY LICENSED PT 52 293.50 19224.91 65.50
SENS-V5014-HEARING AID REPAIR BY MANUFACTURER 1 2.00 228.00 114.00
SENS-V5050-MED HEARING AID - ANALOG/DIGITAL 1 2.00 456.00 228.00
SENS-V5264-EARMOLD 2 4.00 72.00 18.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 144 740.75 47721.60 64.42
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 360 69827.0 34908.00 0.50
Subtotal (Total Children Is Unduplicated) 494 73168.3 217929.65 2.98
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Total 76262.50 318137.14 4.17
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Number of Children (Unduplicated) With at Least One Service 1076
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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 0 0.00 0.00 0.00
P 3832 49981.75 160531.46 160531.46
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 3409 2776.75 85324.28 85305.78
1856 23504.00 72281.40 0.00
Other 0 0.00 0.00 0.00
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Total 9097 76262.50 318137.14 245837.24