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:TPIN
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
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 4 4.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 0.50 18.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 11 16.75 619.75 37.00
Subtotal (Total Children Is Unduplicated) 16 21.25 638.25 30.04
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Screening, Eval, and Assessment,Class #02
AUDE-V5090-DISPENSING FEE PER HEARING AID 2 4.00 478.40 119.60
EVAL-EVAL-DEVELOPMENTAL EVALUATION 6 22.50 1125.00 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 147 207.50 15562.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 7.00 525.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 82 98.50 7387.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 98 154.00 11550.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 25 33.00 1831.50 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 5 7.00 388.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 460 530.00 39750.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 37 48.50 3637.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 277 317.00 23775.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 162 196.00 10878.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 227 257.00 19275.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 7 8.00 388.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 15 15.00 727.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 4 6.00 291.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 11 11.00 533.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 7 7.00 350.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 24 26.00 1261.00 48.50
Subtotal (Total Children Is Unduplicated) 713 1957.00 139825.90 71.45
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 5 8.00 400.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 1.00 50.00 50.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 9 18.00 900.00 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 9 11.00 550.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 9 12.00 600.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 10 34.50 1725.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 274 2356.50 159955.52 67.88
OCCT-97530HM-OT SESSION BY OT ASST 10 52.50 2851.80 54.32
PHY-97110-PT SESSION BY LICENSED PT 247 2043.25 138506.45 67.79
PHY-97110HM-PT SESSION BY PT ASST 7 70.00 3802.40 54.32
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 1 2.00 1000.00 500.00
SENS-V5050-MED HEARING AID - ANALOG/DIGITAL 1 2.00 474.24 237.12
SENS-V5264-EARMOLD 3 8.00 149.76 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 414 3635.00 246790.80 67.89
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 4.50 244.44 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 1 7.00 92.40 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 8 196.00 98.00 0.50
Subtotal (Total Children Is Unduplicated) 643 8461.25 558190.81 65.97
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Total 10439.50 698654.96 66.92
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Number of Children (Unduplicated) With at Least One Service 1133
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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 366 524.00 35124.22 40967.66
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
5906 9915.50 663530.74 3036.00
Other 0 0.00 0.00 0.00
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Total 6272 10439.50 698654.96 44003.66