CMS/EIP Fiscal Report Center: 52
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Payclass Filters:TPIN
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 5 4.50 175.75 39.06
Subtotal (Total Children Is Unduplicated) 5 4.50 175.75 39.06
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.00 8.83 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.00 21.18 10.59
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.00 8.44 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.00 38.79 19.40
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.00 55.47 27.74
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 1.00 50.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 1 1.00 50.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 2.00 97.00 48.50
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 2.00 97.00 48.50
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 3.00 145.50 48.50
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.00 225.00 75.00
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 4 4.00 194.00 48.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 169 217.14 14226.58 65.52
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 15 16.32 862.42 52.84
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 49 57.23 3542.35 61.90
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 120 179.85 10198.60 56.71
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 26 34.50 2802.50 81.23
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 2 2.00 97.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 41 45.26 2195.45 48.51
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 19 19.72 956.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 13 13.00 650.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 64 72.80 3559.39 48.89
Subtotal (Total Children Is Unduplicated) 348 682.82 40130.50 58.77
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EI Services,Class #03
AUD-HA_FUP-AUDIOLOGY SERVICES 2 1.90 94.84 49.92
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 74 511.01 25633.06 50.16
OCCT-97530-OT SESSION BY LICENSED OT 71 659.50 44923.64 68.12
PHY-97110-PT SESSION BY LICENSED PT 88 667.52 45931.06 68.81
PHY-97110HM-PT SESSION BY PT ASST 1 1.00 54.32 54.32
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 1 1.44 721.55 501.08
SENS-V5264-EARMOLD 1 2.00 37.44 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 228 1861.68 127846.44 68.67
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.50 19.80 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 10 412.00 206.00 0.50
Subtotal (Total Children Is Unduplicated) 345 4119.55 245468.15 59.59
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Total 4806.87 285774.40 59.45
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Number of Children (Unduplicated) With at Least One Service 500
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Center 52
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 0 0.00 0.00 0.00
P 103 150.70 11847.26 9731.95
D 1 3.50 237.58 0.00
S 0 0.00 0.00 0.00
H 339 589.50 36218.14 0.00
T 0 0.00 0.00 0.00
2034 4063.17 237471.42 240.00
Other 0 0.00 0.00 0.00
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Total 2477 4806.87 285774.40 9971.95