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: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 1 0.50 18.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 8 8.00 262.50 32.81
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 10 8.50 323.75 38.09
TCM-T1017TL-TARGETED CASE MANAGEMENT 77 172.25 6450.75 37.45
Subtotal (Total Children Is Unduplicated) 82 189.25 7055.50 37.28
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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 14 18.40 1380.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 13 16.50 1950.00 118.18
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 32 43.50 7078.13 162.72
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 34 42.45 3184.70 75.02
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 50 69.91 7017.64 100.38
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 21 26.00 1622.25 62.39
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 186 233.49 37275.04 159.64
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 63 72.13 3469.02 48.09
Subtotal (Total Children Is Unduplicated) 402 843.48 72597.26 86.07
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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 183 1402.67 97512.55 69.52
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) 340 4821.27 250574.73 51.97
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Total 5854.00 330227.49 56.41
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Number of Children (Unduplicated) With at Least One Service 601
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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 106 129.86 27990.44 14970.99
D 1 1.00 262.50 144.38
S 2 2.50 498.30 2.65
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
2811 5720.64 301476.25 292.90
Other 0 0.00 0.00 0.00
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Total 2920 5854.00 330227.49 15410.92