CMS/EIP Fiscal Report Center: 51
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 989 1132.50 41884.00 36.98
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1015 1807.75 66840.50 36.97
TCM-T1017TL-TARGETED CASE MANAGEMENT 1551 13421.8 496231.50 36.97
Subtotal (Total Children Is Unduplicated) 1558 16362.0 604956.00 36.97
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Screening, Eval, and Assessment,Class #02
AUD-92626-EVAL OF AUD REHAB STATUS 2 2.00 72.14 36.07
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 5 5.00 44.15 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 8 8.00 86.40 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 7 7.00 152.53 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.00 27.19 27.19
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.00 31.81 31.81
AUDE-92682-CONDITIONED PLAY AUDIOMETRY 1 1.00 21.34 21.34
AUDE-V5090-DISPENSING FEE PER HEARING AID 2 4.00 478.40 119.60
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 12 12.00 1500.00 125.00
EVAL-EVAL-DEVELOPMENTAL EVALUATION 48 50.50 2525.00 50.00
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 5 5.50 291.50 53.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 23 25.00 1773.50 70.94
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 14 14.00 1050.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 3.50 262.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 46 49.00 3600.00 73.47
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 2.50 130.50 52.20
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 53 70.50 3900.08 55.32
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 309 334.00 24000.00 71.86
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 125 139.00 9830.57 70.72
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 38 43.50 3040.90 69.91
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 36 54.50 2734.50 50.17
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 491 535.50 39020.50 72.87
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 10 10.00 405.00 40.50
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.00 57.27 57.27
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 10 10.00 745.99 74.60
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 38 44.00 2056.81 46.75
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 60 64.00 3056.50 47.76
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 28 32.00 1460.73 45.65
PSTH-97001-EVAL BY LICENSED PT, INITIAL 74 74.00 3589.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 118 130.00 6287.65 48.37
VISF-VISF-VISION EVALUATION FUNCTIONAL 8 31.00 2205.00 71.13
Subtotal (Total Children Is Unduplicated) 768 1764.00 114437.46 64.87
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 39 244.00 34990.56 143.40
AUD-92630-AUD REHAB PRELING HEARING LOSS 3 45.00 2870.33 63.79
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 124 121.50 5646.50 46.47
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 24 78.50 1450.00 18.47
CONIP-CONIP-CONSULT, ITDS, PHONE 1 0.50 12.50 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 6 3.00 137.50 45.83
CONOP-CONOP-CONSULT, OT, PHONE 2 0.50 12.50 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 13 8.25 400.00 48.48
CONPP-CONPP-CONSULT, PT, PHONE 11 5.50 112.50 20.45
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 9 30.25 268.75 8.88
CONSP-CONSP-CONSULT, SLP, PHONE 5 2.00 50.00 25.00
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 3 32.00 2349.44 73.42
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 4 12.00 300.00 25.00
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 7 507.75 25417.50 50.06
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 390 5717.25 275310.00 48.15
INTR-INTR-INTERPRETER 3 5.50 123.50 22.45
OCCT-97530-OT SESSION BY LICENSED OT 209 2929.00 179121.56 61.15
OCCT-97530HM-OT SESSION BY OT ASST 42 346.75 16671.40 48.08
PHY-97110-PT SESSION BY LICENSED PT 217 2994.25 190023.48 63.46
PHY-97110HM-PT SESSION BY PT ASST 46 369.00 19450.70 52.71
SENS-HA_INS-SENSORY AID INSURANCE PER EAR 1 2.00 86.00 43.00
SENS-V5050-MED HEARING AID - ANALOG/DIGITAL 2 4.00 948.48 237.12
SENS-V5264-EARMOLD 3 6.00 110.88 18.48
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 355 4808.00 307483.04 63.95
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 4 15.25 828.38 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 30 75.50 996.60 13.20
TRAN-TRAN-FAMILY TRANSPORTATION 2 180.00 90.00 0.50
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 871 427340 254084.66 0.59
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 1 23.00 1610.00 70.00
Subtotal (Total Children Is Unduplicated) 949 445906 1320956.76 2.96
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Total 464032.25 2040350.22 4.40
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Number of Children (Unduplicated) With at Least One Service 1563
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Center 51
Flag Claims Units Chgs Paid
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R 3 3.00 187.00 0.00
U 0 0.00 0.00 0.00
B 12304 8327.75 317194.86 0.00
P 8703 430192.50 769779.17 769715.29
D 148 95.25 3788.37 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
18447 25413.75 949400.82 5.00
Other 0 0.00 0.00 0.00
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Total 39605 464032.25 2040350.22 769720.29