CMS/EIP Fiscal Report Center: 10
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 14 10.50 388.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 733 810.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 835 1013.75 37508.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 2263 8491.00 314167.00 37.00
TCON-TCON-TRANSITION CONFERENCE 167 167.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 2274 10492.3 352064.25 33.55
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 24 24.00 254.88 10.62
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.00 16.30 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 24 24.00 211.92 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 25 25.00 262.22 10.49
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 22 22.00 441.33 20.06
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 18 18.00 466.52 25.92
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 37 61.00 4575.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 20 32.00 2400.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 21 34.50 2587.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 9 17.00 1275.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 22 37.00 2053.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 342 598.00 44850.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 207 343.00 25725.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 177 266.50 19987.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 169 279.50 15512.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 172 238.00 17850.00 75.00
Subtotal (Total Children Is Unduplicated) 525 2020.50 138468.92 68.53
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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 24 129.00 3225.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 207 2306.75 110560.00 47.93
INTR-INTR-INTERPRETER 2 7.00 350.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 243 882.25 58593.91 66.41
OCCT-97530HM-OT SESSION BY OT ASST 20 56.00 3028.61 54.08
PHY-97110-PT SESSION BY LICENSED PT 329 1258.00 83753.19 66.58
SENS-HA_INS-SENSORY AID INSURANCE PER EAR 1 1.00 65.00 65.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 482 1899.00 128396.13 67.61
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) 801 94365.5 455688.14 4.83
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Total 106878.25 946221.31 8.85
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Number of Children (Unduplicated) With at Least One Service 2320
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Center 10
Flag Claims Units Chgs Paid
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R 5 1.75 64.75 0.00
U 0 0.00 0.00 0.00
B 6561 4180.50 155745.50 0.00
P 4260 87149.50 365982.45 366023.20
D 121 68.00 2516.00 2469.75
S 168 103.75 3838.75 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
10363 15374.75 418073.86 0.00
Other 0 0.00 0.00 0.00
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Total 21478 106878.25 946221.31 368492.95