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:TPIN
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 1 0.50 18.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 6 6.00 262.50 43.75
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 8 7.00 268.25 38.32
TCM-T1017TL-TARGETED CASE MANAGEMENT 66 151.00 5747.75 38.06
Subtotal (Total Children Is Unduplicated) 70 164.50 6297.00 38.28
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 3 3.00 31.86 10.62
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 47 53.00 467.09 8.81
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 55 66.00 711.96 10.79
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 3 3.00 23.67 7.89
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 55 60.04 1303.61 21.71
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 8 15.00 810.04 54.00
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 4 2.84 80.72 28.42
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 25 28.00 896.26 32.01
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 1 1.00 235.80 235.80
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 11 14.90 1117.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 11 14.50 1612.50 111.21
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 22 30.50 4790.63 157.07
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 3.50 194.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 29 36.45 2734.70 75.03
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 37 56.25 5655.14 100.54
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 13 18.00 1178.25 65.46
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 115 153.33 23040.65 150.27
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 10 9.88 479.84 48.57
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 44 46.59 2965.08 63.64
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 10 9.84 478.06 48.58
PSTH-97001-EVAL BY LICENSED PT, INITIAL 18 19.41 942.24 48.54
SPCH-92506-SPEECH EVAL BY LICENSED SLP 61 70.83 3405.52 48.08
Subtotal (Total Children Is Unduplicated) 308 715.86 53155.37 74.25
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EI Services,Class #03
AUD-HA_FUP-AUDIOLOGY SERVICES 4 5.00 246.00 49.20
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 2 2.00 100.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 2 0.75 18.75 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 2 1.00 50.00 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 0.25 12.50 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 3 1.75 87.50 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 32 217.00 22820.24 105.16
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 3 4.00 200.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 181 1388.17 96528.29 69.54
OCCT-97530HM-OT SESSION BY OT ASST 6 24.25 1317.26 54.32
PHY-97110-PT SESSION BY LICENSED PT 90 621.74 42291.52 68.02
SENS-V5264-EARMOLD 2 3.00 56.16 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 172 1245.86 84607.75 67.91
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 13 1292.00 1254.50 0.97
Subtotal (Total Children Is Unduplicated) 338 4806.77 249590.47 51.92
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Total 5687.13 309042.84 54.34
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Number of Children (Unduplicated) With at Least One Service 498
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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 84 102.86 22084.18 11875.02
D 0 0.00 0.00 0.00
S 1 1.00 235.80 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
2690 5583.27 286722.86 229.61
Other 0 0.00 0.00 0.00
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Total 2775 5687.13 309042.84 12104.63