CMS/EIP Fiscal Report Center: 10
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Payclass Filters:MED
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
TCM-T1017TL-TARGETED CASE MANAGEMENT 1849 15997.5 591765.50 36.99
Subtotal (Total Children Is Unduplicated) 1849 15997.5 591765.50 36.99
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 8 8.00 84.96 10.62
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 7 7.00 61.81 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 6 6.00 64.38 10.73
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 5 5.00 108.95 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 5 5.00 141.40 28.28
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 1.00 119.60 119.60
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 77 133.50 10012.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 39 58.50 4387.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 43 65.00 4875.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 19 36.50 2737.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 75 137.00 7603.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 310 510.00 38250.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 191 321.00 24037.50 74.88
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 231 363.50 27262.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 322 559.00 31024.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 268 340.50 25500.00 74.89
Subtotal (Total Children Is Unduplicated) 668 2556.50 176271.60 68.95
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 13 118.00 2950.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 209 3116.50 155825.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 172 1240.25 84120.37 67.83
OCCT-97530HM-OT SESSION BY OT ASST 24 89.25 4848.06 54.32
PHY-97110-PT SESSION BY LICENSED PT 295 2334.75 158455.71 67.87
SENS-V5264-EARMOLD 1 2.00 37.44 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 294 2223.00 150623.84 67.76
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 13 56.75 3082.66 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 3 2.75 36.30 13.20
Subtotal (Total Children Is Unduplicated) 622 9183.25 559979.38 60.98
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Total 27737.25 1328016.48 47.88
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Number of Children (Unduplicated) With at Least One Service 1856
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Center 10
Flag Claims Units Chgs Paid
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R 5 1.75 64.75 0.00
U 0 0.00 0.00 0.00
B 20766 13616.50 530902.13 153.00
P 7080 5896.00 288886.15 289972.85
D 198 139.25 5664.25 5765.25
S 174 109.00 4385.72 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
4186 7974.75 498113.48 0.00
Other 0 0.00 0.00 0.00
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Total 32409 27737.25 1328016.48 295891.10