CMS/EIP Fiscal Report Center: 10
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Eligibility Filter:Part C (excluding not eligible)
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 34 17.25 638.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 709 789.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 713 860.75 31847.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1946 7692.25 284567.00 36.99
TCON-TCON-TRANSITION CONFERENCE 169 169.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1954 9528.25 317053.00 33.28
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 21 22.00 232.25 10.56
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 2 2.00 17.34 8.67
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 25 27.00 197.24 7.31
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 27 30.00 273.64 9.12
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.00 8.44 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 28 30.00 560.99 18.70
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 21 22.25 531.82 23.90
AUDE-V5090-DISPENSING FEE PER HEARING AID 2 3.00 243.80 81.27
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 35 59.50 4462.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 16 22.50 1687.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 14 20.50 1537.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 10 17.00 1275.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 28 51.50 2858.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 197 333.50 25012.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 139 235.50 17662.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 98 160.00 12000.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 172 311.00 17260.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 142 186.00 13912.50 74.80
Subtotal (Total Children Is Unduplicated) 380 1534.25 99734.27 65.01
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 14 65.00 5641.14 86.79
AUD-HA_FUP-AUDIOLOGY SERVICES 5 7.00 338.77 48.40
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 124 152.00 7600.00 50.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 29 25.00 1250.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 1 1.00 25.00 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.00 50.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 26 28.00 1400.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 4 2.00 50.00 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 22 133.75 3343.75 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 211 2035.00 97615.00 47.97
OCCT-97530-OT SESSION BY LICENSED OT 273 1158.25 77147.50 66.61
OCCT-97530HM-OT SESSION BY OT ASST 36 82.50 4390.19 53.21
PHY-97110-PT SESSION BY LICENSED PT 396 1566.00 104489.77 66.72
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 1 2.00 1000.00 500.00
SENS-V5050-MED HEARING AID - ANALOG/DIGITAL 1 1.00 9.12 9.12
SENS-V5264-EARMOLD 2 5.00 85.88 17.18
SHIN-EIIF_NM-INITIAL SHINE SERVICES, IND NONMED 3 5.75 287.50 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 565 2420.75 163538.17 67.56
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 19 68.50 3711.41 54.18
SPL-92508-GROUP SPL SESSION PER CHILD 5 6.75 89.10 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 437 96785.0 48382.50 0.50
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 14 63.75 3187.50 50.00
Subtotal (Total Children Is Unduplicated) 899 104615 523632.30 5.01
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Total 115677.50 940419.57 8.13
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Number of Children (Unduplicated) With at Least One Service 1978
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Center 10
Flag Claims Units Chgs Paid
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R 2 1.75 64.75 0.00
U 0 0.00 0.00 0.00
B 6270 3994.00 149230.50 0.00
P 4326 87642.00 342964.34 342915.27
D 93 76.75 3644.75 3644.75
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
10062 23963.00 444515.23 0.00
Other 0 0.00 0.00 0.00
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Total 20753 115677.50 940419.57 346560.02