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:Program Patients
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 2417 18686.3 691240.00 36.99
Subtotal (Total Children Is Unduplicated) 2417 18686.3 691240.00 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 106 171.50 12862.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 49 71.50 5362.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 61 88.50 6637.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 31 53.50 4012.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 106 180.50 10017.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 457 735.00 55125.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 285 463.50 34725.00 74.92
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 331 491.00 36825.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 532 881.50 48923.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 398 502.50 37650.00 74.93
Subtotal (Total Children Is Unduplicated) 1002 3671.00 252722.10 68.84
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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 210 3117.50 155875.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 173 1243.25 84324.01 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) 624 9187.25 560233.02 60.98
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Total 31544.50 1504195.12 47.68
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Number of Children (Unduplicated) With at Least One Service 2427
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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 23151 15928.00 627110.63 153.00
P 8343 7336.50 366453.40 369377.35
D 234 180.50 7456.50 7557.50
S 186 117.75 4709.47 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
4189 7977.75 498317.12 0.00
Other 1 2.25 83.25 0.00
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Total 36109 31544.50 1504195.12 377087.85