CMS/EIP Fiscal Report Center: 52
Services beginning 01/01/2008 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 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 762 4558.75 166611.00 36.55
TCON-TCON-TRANSITION CONFERENCE 270 273.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1330 8898.25 245874.25 27.63
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Screening, Eval, and Assessment,Class #02
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.00 21.18 10.59
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.00 17.00 17.00
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 2 2.00 108.76 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.00 55.47 27.74
EVAL-EVAL-DEVELOPMENTAL EVALUATION 4 4.00 200.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 30 33.50 1675.00 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 1 2.00 150.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.00 161.00 53.67
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 206 207.50 10373.50 49.99
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 98 137.36 9826.82 71.54
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 5.18 266.58 51.46
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 38 43.76 2568.00 58.68
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 115 172.15 9554.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 33 48.50 3637.50 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 4 4.00 194.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 34 33.74 1636.05 48.49
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 5 5.00 227.94 45.59
PSTH-97001-EVAL BY LICENSED PT, INITIAL 22 25.28 1226.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 18 20.00 1000.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 50 50.20 2419.99 48.21
Subtotal (Total Children Is Unduplicated) 477 806.17 45518.79 56.46
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.00 77.00 38.50
AUD-HA_FUP-AUDIOLOGY SERVICES 1 0.10 5.16 51.60
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 110 132.25 6612.50 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 2 0.75 18.75 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 38 35.75 1787.50 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 4 1.00 25.00 25.00
CONOP-CONOP-CONSULT, OT, PHONE 2 0.75 18.75 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 9 8.50 425.00 50.00
CONPP-CONPP-CONSULT, PT, PHONE 11 7.00 175.00 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 21 18.50 925.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 8 3.00 75.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 112 1179.16 58954.94 50.00
INTR-INTR-INTERPRETER 1 2.00 100.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 62 581.13 39266.67 67.57
PHY-97110-PT SESSION BY LICENSED PT 85 630.17 42743.84 67.83
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 1 0.56 278.45 497.23
SENS-V5264-EARMOLD 1 2.00 37.44 18.72
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 1.50 75.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 222 2441.81 165434.75 67.75
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1005 391247 195614.31 0.50
Subtotal (Total Children Is Unduplicated) 1039 396295 512650.06 1.29
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Total 405998.97 804043.10 1.98
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Number of Children (Unduplicated) With at Least One Service 1345
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Center 52
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 3 0.75 27.75 0.00
P 54 1062.50 1444.88 1377.50
D 1 4.00 200.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 5044 223120.55 315040.63 314934.13
19846 181811.17 487329.84 107.45
Other 0 0.00 0.00 0.00
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Total 24948 405998.97 804043.10 316419.08