CMS/EIP Fiscal Report Center: 07
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 2534 3647.75 134948.25 36.99
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 1321 1796.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 2035 3619.75 133930.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1655 8341.75 308552.25 36.99
TCON-TCON-TRANSITION CONFERENCE 178 181.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 3057 17586.3 577431.25 32.83
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 13 14.00 120.92 8.64
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 13 14.00 149.94 10.71
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 13 14.00 290.69 20.76
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 2 2.00 108.76 54.38
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 2 2.00 63.62 31.81
AUDE-V5090-DISPENSING FEE PER HEARING AID 5 10.00 1141.40 114.14
EVAL-EVAL-DEVELOPMENTAL EVALUATION 22 29.75 1662.50 55.88
EXIT-EXIT-TRANSITION ASSESSMENT 5 9.00 450.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 8 12.00 900.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.00 75.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 4.00 300.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 9 16.00 1200.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 11 16.50 915.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 174 293.50 21638.00 73.72
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 46 70.00 5250.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 31 49.50 3712.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 463 835.00 46317.25 55.47
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 419 903.00 67725.00 75.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 5 6.00 436.68 72.78
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 3 1.00 50.00 50.00
NUTR-NUTR-UNSPECIFIED NUTRITIONAL EVAL 3 3.00 150.00 50.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 14 14.00 646.68 46.19
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 99 108.00 4995.39 46.25
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 6 6.00 273.19 45.53
PSTH-97001-EVAL BY LICENSED PT, INITIAL 64 66.00 3037.12 46.02
SCREEN-T1023-INTERDISCIPLINARY SCREENING 99 99.00 4950.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 274 305.00 14579.70 47.80
Subtotal (Total Children Is Unduplicated) 944 2903.25 181140.09 62.39
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 10 20.00 6979.40 348.97
AUD-HA_FUP-AUDIOLOGY SERVICES 6 6.00 300.00 50.00
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 132 121.00 6050.00 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 13 10.00 250.00 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 9 8.25 412.50 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 12 6.00 150.00 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 16 18.00 900.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 22 20.25 506.25 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 18 43.75 2187.50 50.00
CONPP-CONPP-CONSULT, PT, PHONE 3 3.25 81.25 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 34 69.25 3437.50 49.64
CONSP-CONSP-CONSULT, SLP, PHONE 18 18.25 456.25 25.00
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 2 180.00 9000.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 526 5992.75 299637.50 50.00
INTR-INTR-INTERPRETER 1 2.00 100.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 172 1756.50 108358.78 61.69
OCCT-97530HM-OT SESSION BY OT ASST 14 163.25 8867.74 54.32
PHY-97110-PT SESSION BY LICENSED PT 126 1396.50 86908.47 62.23
PHY-97110HM-PT SESSION BY PT ASST 11 121.75 6396.71 52.54
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 2 4.00 2000.00 500.00
SENS-V5014-HEARING AID REPAIR BY MANUFACTURER 2 5.00 570.00 114.00
SENS-V5264-EARMOLD 8 17.00 315.36 18.55
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 2 3.00 150.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 548 8071.04 531924.44 65.91
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 3 2.50 135.80 54.32
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1190 396935 198181.50 0.50
Subtotal (Total Children Is Unduplicated) 1625 414994 1274256.95 3.07
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Total 435483.79 2032828.29 4.67
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Number of Children (Unduplicated) With at Least One Service 3077
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Center 07
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 0.50 18.50 0.00
P 37546 428769.29 1889877.68 1892060.68
D 122 77.00 3169.78 0.00
S 10 4.25 157.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
6124 6632.75 139605.08 0.00
Other 0 0.00 0.00 0.00
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Total 43803 435483.79 2032828.29 1892060.68