CMS/EIP Fiscal Report Center: 54
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 1381 8239.75 302003.25 36.65
Subtotal (Total Children Is Unduplicated) 1381 8239.75 302003.25 36.65
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 16 16.00 141.28 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 13 17.00 183.60 10.80
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.00 8.44 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 20 25.00 544.75 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 2 2.00 108.76 54.38
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 5 5.00 159.05 31.81
AUDE-V5010-ASSESSMENT FOR HEARING AID 2 2.00 90.00 45.00
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.00 230.00 115.00
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 1 2.00 250.00 125.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 10 12.00 900.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 14 21.00 1575.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 2.00 150.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 66 86.50 6450.00 74.57
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 53 65.00 3607.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 43 55.00 4125.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 80 103.00 7725.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 17 18.50 1387.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 200 242.50 13450.50 55.47
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 318 398.00 29737.50 74.72
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 16 17.00 824.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 39 43.00 2085.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 9 10.00 485.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 21 21.00 1018.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 77 81.00 3881.00 47.91
Subtotal (Total Children Is Unduplicated) 624 1247.50 79118.38 63.42
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 3.00 75.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 337 4211.00 210488.00 49.99
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 3 7.00 350.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 133 1150.65 78105.05 67.88
OCCT-97530HM-OT SESSION BY OT ASST 24 351.50 18876.20 53.70
PHY-97110-PT SESSION BY LICENSED PT 111 1001.25 67964.85 67.88
PHY-97110HM-PT SESSION BY PT ASST 2 16.00 869.12 54.32
SENS-V5264-EARMOLD 2 3.00 56.16 18.72
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 3 4.00 200.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 201 1530.25 103805.49 67.84
SPL-92508-GROUP SPL SESSION PER CHILD 1 4.50 59.40 13.20
Subtotal (Total Children Is Unduplicated) 546 8282.15 480849.27 58.06
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Total 17769.40 861970.90 48.51
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Number of Children (Unduplicated) With at Least One Service 1409
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Center 54
Flag Claims Units Chgs Paid
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R 17 11.25 407.00 0.00
U 0 0.00 0.00 0.00
B 4722 3166.75 119590.98 0.00
P 8392 5712.25 225059.00 262066.36
D 11 8.25 318.25 0.00
S 1 0.75 27.75 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
4345 8870.15 516567.92 0.00
Other 0 0.00 0.00 0.00
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Total 17488 17769.40 861970.90 262066.36