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:GR
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 52 30.50 1128.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 2185 3377.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 2624 4048.75 149803.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 2602 17763.5 657157.00 36.99
TCON-TCON-TRANSITION CONFERENCE 704 706.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 4113 25925.8 808089.25 31.17
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 81 90.00 966.63 10.74
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 4 4.00 49.94 12.49
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 87 99.00 788.99 7.97
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 97 112.00 1087.01 9.71
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.00 8.44 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 97 111.00 2088.15 18.81
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 2 2.00 97.44 48.72
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 83 93.25 2372.27 25.44
AUDE-V5010-ASSESSMENT FOR HEARING AID 4 4.00 185.40 46.35
AUDE-V5090-DISPENSING FEE PER HEARING AID 6 10.00 843.11 84.31
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 35 57.00 4275.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 12 18.50 1387.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 18 30.00 2250.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 9 15.50 1162.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 43 76.00 4218.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 292 492.00 36900.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 194 309.50 23212.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 192 269.00 20175.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 368 645.50 35825.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 168 213.50 16012.50 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 2.00 97.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 692 2655.75 154051.13 58.01
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 40 185.00 24833.27 134.23
AUD-HA_FUP-AUDIOLOGY SERVICES 15 24.00 1153.34 48.06
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 393 717.75 35867.50 49.97
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 7 3.75 93.75 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 3 2.50 125.00 50.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 116 151.50 7575.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 8 2.75 68.75 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 15 17.00 850.00 50.00
CONPP-CONPP-CONSULT, PT, PHONE 1 0.50 12.50 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 156 149.25 7462.50 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 8 3.75 93.75 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 47 459.75 11493.75 25.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 40.00 1782.50 44.56
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 304 6472.50 304660.00 47.07
INTR-INTR-INTERPRETER 3 9.00 450.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 282 2474.25 156909.29 63.42
OCCT-97530HM-OT SESSION BY OT ASST 34 170.25 8876.79 52.14
PHY-97110-PT SESSION BY LICENSED PT 316 2833.75 181261.16 63.97
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 6 11.00 4355.46 395.95
SENS-HA_INS-SENSORY AID INSURANCE PER EAR 2 3.00 195.00 65.00
SENS-V5050-MED HEARING AID - ANALOG/DIGITAL 1 1.00 9.12 9.12
SENS-V5264-EARMOLD 6 14.00 231.32 16.52
SHIN-EIIF_NM-INITIAL SHINE SERVICES, IND NONMED 3 5.75 287.50 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 649 6046.75 407341.60 67.37
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 21 141.00 7630.60 54.12
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 813 453021 226500.50 0.50
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 18 105.25 5262.50 50.00
Subtotal (Total Children Is Unduplicated) 1263 473066 1395382.45 2.95
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Total 501647.50 2357522.83 4.70
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Number of Children (Unduplicated) With at Least One Service 4169
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Center 10
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 20 10.00 370.00 0.00
P 15234 346914.75 1246278.75 1246426.75
D 477 351.00 14904.75 14849.25
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
37424 154369.25 1095876.83 0.00
Other 2 2.50 92.50 92.50
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Total 53157 501647.50 2357522.83 1261368.50