CMS/EIP Fiscal Report Center: 51
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 989 1132.50 41884.00 36.98
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1015 1807.75 66840.50 36.97
TCM-T1017TL-TARGETED CASE MANAGEMENT 747 5498.50 203213.25 36.96
Subtotal (Total Children Is Unduplicated) 1414 8438.75 311937.75 36.96
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Screening, Eval, and Assessment,Class #02
AUD-92626-EVAL OF AUD REHAB STATUS 1 1.00 36.07 36.07
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 5 5.00 44.15 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 7 7.00 75.60 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 10 11.00 750.00 68.18
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 8 8.00 600.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 11 12.00 825.00 68.75
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.50 75.00 50.00
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 50 66.00 3650.33 55.31
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 196 210.00 14700.00 70.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 83 89.00 6118.07 68.74
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 23 25.50 1690.90 66.31
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 16 27.00 1208.25 44.75
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 213 225.50 16025.00 71.06
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 7 7.00 283.50 40.50
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.00 57.27 57.27
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 7 7.00 509.46 72.78
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 9 11.00 456.31 41.48
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 32 32.00 1552.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 10 11.00 442.23 40.20
PSTH-97001-EVAL BY LICENSED PT, INITIAL 24 24.00 1164.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 63 69.00 3329.15 48.25
VISF-VISF-VISION EVALUATION FUNCTIONAL 8 31.00 2205.00 71.13
Subtotal (Total Children Is Unduplicated) 508 964.50 60900.06 63.14
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 33 184.00 19428.30 105.59
AUD-92630-AUD REHAB PRELING HEARING LOSS 3 45.00 2870.33 63.79
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 124 120.50 5596.50 46.44
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
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 7 507.75 25417.50 50.06
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 159 2213.50 100468.50 45.39
INTR-INTR-INTERPRETER 3 5.50 123.50 22.45
OCCT-97530-OT SESSION BY LICENSED OT 103 1439.50 78346.16 54.43
OCCT-97530HM-OT SESSION BY OT ASST 10 89.50 2697.58 30.14
PHY-97110-PT SESSION BY LICENSED PT 90 1197.00 68400.27 57.14
PHY-97110HM-PT SESSION BY PT ASST 7 33.50 1662.72 49.63
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 227 3132.00 194402.21 62.07
SPL-92508-GROUP SPL SESSION PER CHILD 8 31.00 409.20 13.20
TRAN-TRAN-FAMILY TRANSPORTATION 2 180.00 90.00 0.50
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 871 426830 253829.66 0.59
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 1 23.00 1610.00 70.00
Subtotal (Total Children Is Unduplicated) 928 436172 758941.54 1.74
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Total 445575.50 1131779.35 2.54
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Number of Children (Unduplicated) With at Least One Service 1467
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Center 51
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 1 0.50 18.50 0.00
P 8670 429850.75 765001.17 765005.17
D 147 94.25 3713.37 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
14448 15630.00 363046.31 5.00
Other 0 0.00 0.00 0.00
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Total 23266 445575.50 1131779.35 765010.17