CMS/EIP Fiscal Report Center: 54
Services beginning 10/01/2008 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 303 122.75 4532.50 36.92
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 273 277.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 599 678.25 25086.00 36.99
TCM-T1017TL-TARGETED CASE MANAGEMENT 1330 4184.75 153476.00 36.68
TCON-TCON-TRANSITION CONFERENCE 1 1.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1339 5263.75 183094.50 34.78
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.00 10.62 10.62
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 21 22.00 194.26 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 44 46.00 496.80 10.80
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 9 9.00 75.96 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 43 44.00 958.76 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 2 3.00 163.14 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 15 15.00 424.20 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 11 12.00 381.72 31.81
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 2 2.60 325.00 125.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 11 13.00 975.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 27 35.50 2662.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 2.00 150.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 29 37.50 2990.63 79.75
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 20 27.50 1526.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 38 44.50 3337.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 124 151.50 11756.26 77.60
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 9.50 712.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 81 110.00 6105.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 133 170.00 14662.54 86.25
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 6 7.00 339.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 25 25.00 1487.00 59.48
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 6 8.00 388.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 11 11.00 533.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 72 72.00 3460.47 48.06
Subtotal (Total Children Is Unduplicated) 423 878.60 54117.11 61.59
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 3 2.50 125.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 65 69.25 3462.50 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 8 3.25 81.25 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 31 27.50 1375.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 4 1.25 31.25 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 7 3.25 162.50 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 54 57.75 2887.50 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 9 164.50 8225.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 331 2129.00 108352.84 50.89
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 7 13.00 650.00 50.00
INTR-INTR-INTERPRETER 20 120.00 6000.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 162 1072.25 72784.33 67.88
OCCT-97530HM-OT SESSION BY OT ASST 2 5.25 285.18 54.32
PHY-97110-PT SESSION BY LICENSED PT 90 486.09 32989.68 67.87
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 1.00 50.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 281 1610.00 109371.67 67.93
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 704 172333 146573.75 0.85
Subtotal (Total Children Is Unduplicated) 847 178099 493407.45 2.77
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Total 184241.19 730619.06 3.97
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Number of Children (Unduplicated) With at Least One Service 1413
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Center 54
Flag Claims Units Chgs Paid
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R 15 10.50 379.25 0.00
U 0 0.00 0.00 0.00
B 1143 705.75 26199.50 0.00
P 5357 148409.14 384796.01 418932.57
D 21 13.75 508.75 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
6811 35102.05 318735.55 0.00
Other 0 0.00 0.00 0.00
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Total 13347 184241.19 730619.06 418932.57