CMS/EIP Fiscal Report Center: 10
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Payclass Filters:GR
Eligibility Filter:Part C (excluding not eligible)
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 12 7.25 268.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 727 804.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 727 896.25 33161.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1042 3682.75 136261.75 37.00
TCON-TCON-TRANSITION CONFERENCE 166 166.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1521 5556.25 169691.25 30.54
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 10 10.00 106.20 10.62
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.00 16.30 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 10 10.00 88.30 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 12 12.00 123.08 10.26
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 14 14.00 267.01 19.07
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 9 9.00 232.17 25.80
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 7.50 562.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.50 112.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 8.00 600.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 9.00 499.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 46 83.00 6225.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 31 45.50 3412.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 28 41.50 3112.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 35 63.00 3496.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 11 15.00 1125.00 75.00
Subtotal (Total Children Is Unduplicated) 85 330.00 19979.06 60.54
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 11 49.00 10851.62 221.46
AUD-HA_FUP-AUDIOLOGY SERVICES 1 1.00 50.00 50.00
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 128 144.75 7237.50 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 1 1.00 25.00 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 31 32.75 1637.50 50.00
CONOP-CONOP-CONSULT, OT, PHONE 7 1.75 43.75 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 2 2.00 100.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 34 34.75 1737.50 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 2 0.50 12.50 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 17 93.00 2325.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 132 1641.50 77297.50 47.09
INTR-INTR-INTERPRETER 2 7.00 350.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 126 477.00 31085.54 65.17
OCCT-97530HM-OT SESSION BY OT ASST 17 49.50 2675.53 54.05
PHY-97110-PT SESSION BY LICENSED PT 149 652.25 42634.88 65.37
SENS-HA_INS-SENSORY AID INSURANCE PER EAR 1 1.00 65.00 65.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 277 1270.25 85716.58 67.48
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 8 42.00 2262.43 53.87
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 387 87517.0 43758.50 0.50
Subtotal (Total Children Is Unduplicated) 621 92018.0 309866.33 3.37
----------------------------------------------------------------------------------------------------------------
Total 97904.25 499536.64 5.10
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1625
----------------------------------------------------------------------------------------------------------------
Center 10
Flag Claims Units Chgs Paid
-------------------------------------------------
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 3630 86233.75 302519.89 302519.89
D 94 52.50 1942.50 1942.50
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
7976 11618.00 195074.25 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 11700 97904.25 499536.64 304462.39