CMS/EIP Fiscal Report Center: 07
Services beginning 10/01/2008 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 999 850.50 31450.00 36.98
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 380 393.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 582 813.75 30108.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1513 4476.75 165445.50 36.96
TCON-TCON-TRANSITION CONFERENCE 36 36.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1622 6570.00 227004.25 34.55
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 4 4.00 87.49 21.87
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 4 4.00 74.40 18.60
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 4 4.00 115.37 28.84
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.00 54.38 54.38
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.00 31.81 31.81
AUDE-V5090-DISPENSING FEE PER HEARING AID 2 4.00 478.40 119.60
EXIT-EXIT-TRANSITION ASSESSMENT 5 9.00 450.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 0.00 0.00 0.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.00 75.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 6.00 450.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 4.00 222.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 46 83.50 5914.50 70.83
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 13 20.50 1537.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 13 18.00 1350.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 147 286.00 15853.75 55.43
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 226 650.00 48750.00 75.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 2 2.00 145.56 72.78
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 3 3.00 145.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 28 28.00 1358.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 3 3.00 145.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 12 12.00 523.56 43.63
SCREEN-T1023-INTERDISCIPLINARY SCREENING 46 46.00 2300.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 74 74.00 3540.05 47.84
Subtotal (Total Children Is Unduplicated) 420 1264.00 83602.77 66.14
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.00 280.00 280.00
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 21 17.75 887.50 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 1 0.50 12.50 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 2 2.00 100.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 3 1.00 25.00 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 5 5.25 262.50 50.00
CONOP-CONOP-CONSULT, OT, PHONE 8 5.50 137.50 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 14 17.00 850.00 50.00
CONPP-CONPP-CONSULT, PT, PHONE 1 0.50 12.50 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 15 14.75 737.50 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 7 3.00 75.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 450 2703.50 135175.00 50.00
INTR-INTR-INTERPRETER 1 2.00 100.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 99 501.75 32226.73 64.23
OCCT-97530HM-OT SESSION BY OT ASST 5 42.00 2281.44 54.32
PHY-97110-PT SESSION BY LICENSED PT 71 359.25 22008.00 61.26
PHY-97110HM-PT SESSION BY PT ASST 8 27.00 1466.64 54.32
SENS-V5264-EARMOLD 3 6.00 112.32 18.72
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 3 4.50 225.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 318 2164.79 144455.51 66.73
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 4 4.00 217.28 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 1 0.50 6.60 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 553 94633.0 47229.50 0.50
Subtotal (Total Children Is Unduplicated) 872 100517 388884.02 3.87
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Total 108350.54 699491.04 6.46
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Number of Children (Unduplicated) With at Least One Service 1709
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Center 07
Flag Claims Units Chgs Paid
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R 1 0.50 18.50 0.00
U 0 0.00 0.00 0.00
B 2100 1530.25 61968.00 0.00
P 8767 101251.04 460682.62 462850.37
D 68 46.00 1987.00 0.00
S 168 136.50 6016.50 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
3678 5386.25 168818.42 0.00
Other 0 0.00 0.00 0.00
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Total 14782 108350.54 699491.04 462850.37