CMS/EIP Fiscal Report Center: 52
Services beginning 01/01/2008 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 995 988.50 36546.75 36.97
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 893 1923.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1080 1155.00 42716.50 36.98
TCM-T1017TL-TARGETED CASE MANAGEMENT 1329 8384.25 307092.75 36.63
TCON-TCON-TRANSITION CONFERENCE 270 273.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1362 12723.8 386356.00 30.36
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 2 2.00 16.76 8.38
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 5 5.00 52.74 10.55
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.00 8.44 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 5 5.00 94.58 18.92
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 2 2.00 108.76 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 5 5.00 138.13 27.63
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.00 18.00 18.00
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 2 2.00 225.00 112.50
EVAL-EVAL-DEVELOPMENTAL EVALUATION 12 12.50 633.25 50.66
EXIT-EXIT-TRANSITION ASSESSMENT 31 34.50 1725.00 50.00
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 4 4.00 200.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 11 15.00 947.00 63.13
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 2.00 97.00 48.50
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 6 7.00 445.50 63.64
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 4.50 337.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 8 11.50 632.75 55.02
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 207 216.50 10811.50 49.94
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 511 704.50 47370.40 67.24
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 32 37.00 1978.00 53.46
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 137 167.49 10859.35 64.84
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 444 661.50 36929.85 55.83
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 104 143.50 10977.50 76.50
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 12 12.00 582.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 133 144.00 6984.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 14 18.00 858.44 47.69
PSTH-97001-EVAL BY LICENSED PT, INITIAL 95 104.00 5044.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 48 50.00 2500.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 187 203.00 9844.82 48.50
Subtotal (Total Children Is Unduplicated) 952 2575.49 150420.27 58.40
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 4 4.00 1177.00 294.25
AUD-HA_FUP-AUDIOLOGY SERVICES 2 2.00 100.00 50.00
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 124 159.50 7975.00 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 2 0.75 18.75 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 43 40.25 2012.50 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 9 2.50 62.50 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 3 2.75 137.50 50.00
CONOP-CONOP-CONSULT, OT, PHONE 2 0.75 18.75 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 10 10.50 525.00 50.00
CONPP-CONPP-CONSULT, PT, PHONE 11 7.00 175.00 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 25 22.50 1125.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 10 3.50 87.50 25.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 91 1210.25 38847.50 32.10
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 276 3341.42 157260.50 47.06
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 1 32.00 1600.00 50.00
INTR-INTR-INTERPRETER 1 2.00 100.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 192 2465.63 167153.47 67.79
PHY-97110-PT SESSION BY LICENSED PT 210 2614.29 178044.35 68.10
PHY-97110HM-PT SESSION BY PT ASST 5 25.75 1405.52 54.58
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 1 2.00 1000.00 500.00
SENS-V5264-EARMOLD 2 4.00 74.88 18.72
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 2 4.00 200.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 527 6257.48 425904.16 68.06
SPL-92508-GROUP SPL SESSION PER CHILD 2 2.50 33.00 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1011 399436 199708.50 0.50
Subtotal (Total Children Is Unduplicated) 1065 415653 1184746.38 2.85
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Total 430952.56 1721522.65 3.99
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Number of Children (Unduplicated) With at Least One Service 1369
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Center 52
Flag Claims Units Chgs Paid
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R 9 8.25 543.59 0.00
U 0 0.00 0.00 0.00
B 4733 2924.50 123137.37 60.16
P 3536 3285.70 103096.88 100886.59
D 2 7.50 437.58 0.00
S 9 25.25 934.25 0.00
H 339 589.50 36218.14 0.00
T 5044 223120.55 315040.63 314934.13
25342 200991.31 1142114.21 347.45
Other 0 0.00 0.00 0.00
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Total 39014 430952.56 1721522.65 416228.33