CMS/EIP Fiscal Report Center: 54
Services beginning 01/01/2008 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 842 492.25 18139.25 36.85
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 778 992.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1305 2101.50 77322.75 36.79
TCM-T1017TL-TARGETED CASE MANAGEMENT 1126 6178.25 226356.75 36.64
TCON-TCON-TRANSITION CONFERENCE 1 1.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1907 9765.00 321818.75 32.96
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.00 12.25 12.25
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 2 2.00 32.60 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 24 26.00 226.88 8.73
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 73 79.00 851.10 10.77
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 20 20.00 167.15 8.36
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 71 72.96 1575.30 21.59
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 4 5.00 271.90 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 31 30.16 852.52 28.27
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 18 18.00 583.74 32.43
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.00 212.00 106.00
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 4 4.00 500.00 125.00
EVAL-EVAL-DEVELOPMENTAL EVALUATION 2 1.50 87.50 58.33
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 20 23.60 1732.50 73.41
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 29 31.00 2287.50 73.79
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 3.00 225.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 8 9.50 712.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 31 40.50 2247.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 110 122.55 8927.80 72.85
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 199 214.25 15880.62 74.12
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 10 12.00 900.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 138 181.50 10073.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 134 166.17 12462.50 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 16 15.12 732.66 48.46
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 75 71.27 3455.06 48.48
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 12 12.16 571.97 47.04
PSTH-97001-EVAL BY LICENSED PT, INITIAL 24 22.59 1094.76 48.46
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 1.00 50.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 129 125.17 6068.95 48.49
Subtotal (Total Children Is Unduplicated) 654 1313.00 72795.76 55.44
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.00 236.58 118.29
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 36 35.00 1750.00 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 1 0.50 12.50 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 147 181.00 9050.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 29 10.75 268.75 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 79 89.75 4487.50 50.00
CONOP-CONOP-CONSULT, OT, PHONE 10 3.25 81.25 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 26 22.50 1125.00 50.00
CONPP-CONPP-CONSULT, PT, PHONE 1 0.25 6.25 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 124 163.50 8175.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 12 4.25 106.25 25.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 16 734.25 36712.50 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 288 4467.50 208844.00 46.75
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 4 13.00 650.00 50.00
INTR-INTR-INTERPRETER 31 332.75 16637.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 243 3283.77 204477.19 62.27
OCCT-97530HM-OT SESSION BY OT ASST 2 4.00 217.28 54.32
PHY-97110-PT SESSION BY LICENSED PT 103 920.98 62207.93 67.55
PHY-97110HM-PT SESSION BY PT ASST 1 1.00 54.32 54.32
SENS-HA_INS-SENSORY AID INSURANCE PER EAR 1 2.00 130.00 65.00
SENS-V5264-EARMOLD 3 8.00 149.76 18.72
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 3 5.00 250.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 277 3043.93 206571.88 67.86
TRAN-TRAN-FAMILY TRANSPORTATION 1 84.00 84.00 1.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1092 583591 535304.80 0.92
Subtotal (Total Children Is Unduplicated) 1237 597004 1297590.24 2.17
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Total 608081.93 1692204.75 2.78
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Number of Children (Unduplicated) With at Least One Service 1965
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Center 54
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 11024 518547.18 1249868.97 1249868.97
D 386 240.75 9403.76 0.00
S 1 98.00 235.80 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
16070 89196.00 432696.22 0.00
Other 0 0.00 0.00 0.00
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Total 27481 608081.93 1692204.75 1249868.97