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: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 1187 4215.50 155973.50 37.00
TCON-TCON-TRANSITION CONFERENCE 167 167.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1710 6216.75 193870.75 31.19
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 13 13.00 138.06 10.62
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.00 16.30 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 13 13.00 114.79 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 15 15.00 154.22 10.28
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 17 17.00 332.38 19.55
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 13 13.00 325.12 25.01
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 11.00 825.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.50 262.50 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 6 11.00 610.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 73 125.50 9412.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 47 69.50 5212.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 45 63.00 4725.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 51 88.50 4911.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 31 39.50 2962.50 75.00
Subtotal (Total Children Is Unduplicated) 135 491.50 30603.12 62.26
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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 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
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Total 98726.25 534340.20 5.41
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Number of Children (Unduplicated) With at Least One Service 1821
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Center 10
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 3646 86249.75 302767.70 302767.70
D 103 57.75 2136.75 2090.50
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
8792 12418.75 229435.75 0.00
Other 0 0.00 0.00 0.00
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Total 12541 98726.25 534340.20 304858.20