CMS/EIP Fiscal Report Center: 05
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 769 460.50 17038.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 806 1416.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 927 1303.75 48238.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1407 10237.0 378722.75 37.00
Subtotal (Total Children Is Unduplicated) 1416 13417.3 444000.00 33.09
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 2 2.00 17.66 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.00 21.60 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.00 21.79 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.00 56.56 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 3 3.00 95.43 31.81
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 1.00 119.60 119.60
EVAL-EVAL-DEVELOPMENTAL EVALUATION 36 46.00 2371.75 51.56
EXIT-EXIT-TRANSITION ASSESSMENT 25 45.00 2250.00 50.00
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 3 3.50 194.25 55.50
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 8 8.37 557.76 66.64
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.00 225.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 22 22.50 1687.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 22 22.50 1687.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 7.00 388.50 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 81 95.00 5272.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 211 259.15 17807.50 68.72
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 47 53.09 3981.66 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 96 113.08 8269.50 73.13
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 223 338.00 18759.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 56 71.00 5325.00 75.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 54 54.00 4112.02 76.15
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 27 36.00 1918.26 53.29
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 27 29.00 1391.94 48.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 48 49.00 2403.00 49.04
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 46 53.00 2570.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 26 26.00 1261.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 41 47.00 2350.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 76 81.00 3896.06 48.10
Subtotal (Total Children Is Unduplicated) 634 1473.19 89012.84 60.42
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 7 25.00 3575.87 143.03
AUD-HA_FUP-AUDIOLOGY SERVICES 2 2.00 100.00 50.00
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 222 222.00 11137.50 50.17
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 5 2.00 50.00 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 436 690.75 34537.50 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 29 10.00 250.00 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 154 105.25 5262.50 50.00
CONOP-CONOP-CONSULT, OT, PHONE 13 13.50 362.50 26.85
CONPF-CONPF-CONSULT, PT, FACE TO FACE 180 151.25 7562.50 50.00
CONPP-CONPP-CONSULT, PT, PHONE 2 0.50 12.50 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 271 220.00 11000.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 11 3.75 93.75 25.00
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 3 7.00 175.00 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 9 19.25 481.25 25.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 164 1950.93 75762.64 38.83
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 508 6136.70 306761.87 49.99
HERN-EIIF_NM-EI HEARING SERVICES AFTER SHINE NONMED 1 5.00 250.00 50.00
INTR-INTR-INTERPRETER 11 134.50 6725.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 212 2166.61 133637.69 61.68
OCCT-97530HM-OT SESSION BY OT ASST 12 62.75 3408.58 54.32
PHY-97110-PT SESSION BY LICENSED PT 248 2561.83 167285.97 65.30
PHY-97110HM-PT SESSION BY PT ASST 4 4.50 244.44 54.32
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 1 2.00 1000.00 500.00
SENS-V5264-EARMOLD 2 4.00 74.88 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 418 4408.01 292189.72 66.29
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 29 127.00 6898.64 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 22 71.50 943.80 13.20
TRAN-TRAN-FAMILY TRANSPORTATION 1 98.00 1875.23 19.14
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 719 335653 167797.00 0.50
Subtotal (Total Children Is Unduplicated) 846 354859 1239456.33 3.49
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Total 369749.02 1772469.17 4.79
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Number of Children (Unduplicated) With at Least One Service 1416
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Center 05
Flag Claims Units Chgs Paid
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R 70 71.75 4671.79 0.00
U 0 0.00 0.00 0.00
B 9352 5051.00 188068.90 250.00
P 15181 328931.04 702758.47 703129.84
D 0 0.00 0.00 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
29295 35695.23 876970.01 0.00
Other 0 0.00 0.00 0.00
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Total 53898 369749.02 1772469.17 703379.84