CMS/EIP Fiscal Report Center: 54
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 981 552.75 20377.75 36.87
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 821 1037.00 262.50 0.25
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1695 2637.50 97108.50 36.82
TCM-T1017TL-TARGETED CASE MANAGEMENT 2631 15835.0 580330.00 36.65
TCON-TCON-TRANSITION CONFERENCE 1 1.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 2636 20063.3 698078.75 34.79
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 3 4.00 44.11 11.03
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 2 2.00 32.60 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 85 95.00 835.25 8.79
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 136 163.00 1757.04 10.78
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 24 24.00 199.26 8.30
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 143 158.00 3423.66 21.67
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 14 22.00 1190.70 54.12
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 33 33.00 933.24 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 47 52.00 1676.44 32.24
AUDE-V5010-ASSESSMENT FOR HEARING AID 2 2.00 90.00 45.00
AUDE-V5090-DISPENSING FEE PER HEARING AID 2 4.00 442.00 110.50
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 6 7.00 985.80 140.83
EVAL-EVAL-DEVELOPMENTAL EVALUATION 2 1.50 87.50 58.33
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 47 58.50 4350.00 74.36
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 64 76.50 6412.50 83.82
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 6 6.00 450.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 112 145.50 14690.63 100.97
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 96 122.50 6798.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 223 269.50 19875.00 73.75
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 443 510.00 39835.76 78.11
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 33 37.00 2775.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 434 537.00 29974.50 55.82
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 720 893.00 86625.04 97.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 42 44.00 2134.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 148 160.86 8505.64 52.88
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 28 32.00 1535.03 47.97
PSTH-97001-EVAL BY LICENSED PT, INITIAL 60 63.00 3055.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 1.00 50.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 261 279.00 13452.47 48.22
Subtotal (Total Children Is Unduplicated) 1508 3802.86 252217.42 66.32
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.00 236.58 118.29
AUD-HA_FUP-AUDIOLOGY SERVICES 4 5.00 246.00 49.20
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 149 183.00 9150.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 32 12.75 318.75 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 80 90.75 4537.50 50.00
CONOP-CONOP-CONSULT, OT, PHONE 10 3.25 81.25 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 27 22.75 1137.50 50.00
CONPP-CONPP-CONSULT, PT, PHONE 1 0.25 6.25 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 126 165.25 8262.50 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 12 4.25 106.25 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 3.00 75.00 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 604 8897.50 442252.24 49.71
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 7 24.00 1200.00 50.00
INTR-INTR-INTERPRETER 31 332.75 16637.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 398 5898.09 384235.47 65.15
OCCT-97530HM-OT SESSION BY OT ASST 32 379.75 20410.74 53.75
PHY-97110-PT SESSION BY LICENSED PT 223 2592.47 175756.48 67.79
PHY-97110HM-PT SESSION BY PT ASST 3 17.00 923.44 54.32
SENS-HA_INS-SENSORY AID INSURANCE PER EAR 1 2.00 130.00 65.00
SENS-V5264-EARMOLD 7 14.00 262.08 18.72
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 6 9.00 450.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 531 5875.79 398769.43 67.87
SPL-92508-GROUP SPL SESSION PER CHILD 1 4.50 59.40 13.20
TRAN-TRAN-FAMILY TRANSPORTATION 1 84.00 84.00 1.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1386 601097 551518.70 0.92
Subtotal (Total Children Is Unduplicated) 1628 626490 2055322.06 3.28
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Total 650355.96 3005618.23 4.62
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Number of Children (Unduplicated) With at Least One Service 2686
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Center 54
Flag Claims Units Chgs Paid
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R 17 11.25 407.00 0.00
U 0 0.00 0.00 0.00
B 4722 3166.75 119590.98 0.00
P 20154 536200.42 1546807.80 1570795.71
D 452 284.00 11299.01 144.38
S 4 101.25 761.85 2.65
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
25801 110592.29 1326751.59 292.90
Other 0 0.00 0.00 0.00
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Total 51150 650355.96 3005618.23 1571235.64