CMS/EIP Fiscal Report Center: 10
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Payclass Filters:GR
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 960 3660.25 135429.25 37.00
TCON-TCON-TRANSITION CONFERENCE 169 169.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1488 5496.25 167915.25 30.55
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 17 18.00 189.77 10.54
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 2 2.00 17.34 8.67
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 21 23.00 161.92 7.04
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 24 27.00 242.08 8.97
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.00 8.44 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 23 25.00 452.04 18.08
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 17 18.25 418.70 22.94
AUDE-V5090-DISPENSING FEE PER HEARING AID 2 2.00 124.20 62.10
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 7.50 562.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.00 225.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.00 150.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 6.50 360.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 43 74.50 5587.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 27 45.50 3412.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 15 21.00 1575.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 36 65.00 3607.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 20 26.50 1987.50 75.00
Subtotal (Total Children Is Unduplicated) 91 367.75 19082.74 51.89
----------------------------------------------------------------------------------------------------------------
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 16 101.75 2543.75 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 133 1406.75 66202.50 47.06
OCCT-97530-OT SESSION BY LICENSED OT 134 537.00 35017.73 65.21
OCCT-97530HM-OT SESSION BY OT ASST 21 51.25 2692.69 52.54
PHY-97110-PT SESSION BY LICENSED PT 161 622.75 40461.96 64.97
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 3.00 48.44 16.15
SHIN-EIIF_NM-INITIAL SHINE SERVICES, IND NONMED 3 5.75 287.50 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 298 1333.25 89718.67 67.29
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 10 45.00 2434.89 54.11
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) 666 101239 308342.16 3.05
----------------------------------------------------------------------------------------------------------------
Total 107103.25 495340.15 4.62
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1594
----------------------------------------------------------------------------------------------------------------
Center 10
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 19 9.75 360.75 0.00
P 3729 86831.25 289843.77 289843.77
D 18 17.25 892.25 892.25
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
7954 20245.00 204243.38 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 11720 107103.25 495340.15 290736.02