CMS/EIP Fiscal Report Center: 07
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 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 783 2221.75 82121.50 36.96
TCON-TCON-TRANSITION CONFERENCE 36 36.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1429 4315.00 143680.25 33.30
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 3 3.00 26.49 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 3 3.00 32.40 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 3 3.00 65.37 21.79
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 1 2.00 150.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.00 111.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 41 74.00 5202.00 70.30
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 12 17.00 1275.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 75 143.50 7945.00 55.37
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 106 303.50 22762.50 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 22 22.00 1067.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 2 2.00 97.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 7 7.00 281.06 40.15
SCREEN-T1023-INTERDISCIPLINARY SCREENING 16 16.00 800.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 66 66.00 3152.05 47.76
Subtotal (Total Children Is Unduplicated) 265 705.50 45885.02 65.04
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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 240 1319.00 65950.00 50.00
INTR-INTR-INTERPRETER 1 2.00 100.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 77 402.50 25693.28 63.83
OCCT-97530HM-OT SESSION BY OT ASST 5 37.00 2009.84 54.32
PHY-97110-PT SESSION BY LICENSED PT 56 317.50 19380.59 61.04
PHY-97110HM-PT SESSION BY PT ASST 5 21.00 1140.72 54.32
SENS-V5264-EARMOLD 3 6.00 112.32 18.72
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 2.00 100.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 286 1993.29 132814.09 66.63
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 3 2.50 135.80 54.32
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 552 94296.0 47061.00 0.50
Subtotal (Total Children Is Unduplicated) 830 98467.0 297877.64 3.03
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Total 103487.54 487442.91 4.71
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Number of Children (Unduplicated) With at Least One Service 1569
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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 7516 99929.79 417077.84 419260.84
D 66 45.00 1950.00 0.00
S 2 1.00 37.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
2918 3511.25 68359.57 0.00
Other 0 0.00 0.00 0.00
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Total 10503 103487.54 487442.91 419260.84