CMS/EIP Fiscal Report Center: 09
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 1878 2853.50 105561.25 36.99
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 1216 1606.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1958 2736.00 101111.75 36.96
TCM-T1017TL-TARGETED CASE MANAGEMENT 2160 12780.5 472083.00 36.94
TCON-TCON-TRANSITION CONFERENCE 416 421.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 3212 20397.0 678756.00 33.28
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Screening, Eval, and Assessment,Class #02
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 2.00 93.60 46.80
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.00 239.20 119.60
EVAL-EVAL-DEVELOPMENTAL EVALUATION 44 73.75 3687.50 50.00
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 1 2.00 111.00 55.50
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 87 125.50 9412.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 20 30.00 2250.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 34 44.50 3337.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 56 78.00 5850.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 28 41.00 2275.50 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 4 5.00 277.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 311 502.50 37681.20 74.99
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 291 537.00 40275.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 174 270.50 20287.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 385 681.50 37823.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 170 255.50 19162.50 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 6 6.00 291.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 17 20.00 970.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 16 20.00 970.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 41 49.00 2376.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 104 110.00 5500.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 111 137.00 6561.17 47.89
Subtotal (Total Children Is Unduplicated) 1009 2992.75 199432.42 66.64
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EI Services,Class #03
AUD-HA_FUP-AUDIOLOGY SERVICES 1 1.00 50.00 50.00
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 188 320.50 16025.00 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 2 2.25 56.25 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 58 137.50 6875.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 1 0.03 0.63 21.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 60 116.50 5805.00 49.83
CONOP-CONOP-CONSULT, OT, PHONE 2 0.50 12.50 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 36 103.75 5187.50 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 95 184.50 9225.00 50.00
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 9 42.00 3083.64 73.42
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 4 11.00 275.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 430 6533.00 317010.00 48.52
INTR-INTR-INTERPRETER 48 163.00 8150.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 397 4870.00 321311.80 65.98
OCCT-97530HM-OT SESSION BY OT ASST 12 34.50 1874.04 54.32
PHY-97110-PT SESSION BY LICENSED PT 289 3500.25 224984.63 64.28
PHY-97110HM-PT SESSION BY PT ASST 6 63.25 3418.94 54.05
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 2 4.00 2000.00 500.00
SENS-V5050-MED HEARING AID - ANALOG/DIGITAL 1 2.00 474.24 237.12
SENS-V5264-EARMOLD 4 8.00 149.76 18.72
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 1.00 50.00 50.00
SIC-SIC-SPECIAL INSTRUCTION CONSULTATION 2 8.00 400.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 817 11017.8 737818.07 66.97
SPL-92508-GROUP SPL SESSION PER CHILD 2 2.00 26.40 13.20
TRAN-TRAN-FAMILY TRANSPORTATION 1 30.00 3000.00 100.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1268 412079 205722.00 0.50
Subtotal (Total Children Is Unduplicated) 1693 439235 1872985.40 4.26
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Total 462625.03 2751173.82 5.95
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Number of Children (Unduplicated) With at Least One Service 3354
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Center 09
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 50870 457928.53 2697089.95 2697022.76
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 0 0.00 0.00 0.00
685 4696.50 54083.87 1643.63
Other 0 0.00 0.00 0.00
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Total 51555 462625.03 2751173.82 2698666.39