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:MED
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
TCM-T1017TL-TARGETED CASE MANAGEMENT 1020 4032.00 149137.75 36.99
Subtotal (Total Children Is Unduplicated) 1020 4032.00 149137.75 36.99
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 2 2.00 21.24 10.62
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 2 2.00 17.66 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.00 10.38 10.38
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.00 21.79 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.00 28.28 28.28
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 1.00 119.60 119.60
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 22 40.00 3000.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 11 16.00 1200.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 9 14.00 1050.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 8.00 600.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 17 32.00 1776.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 92 149.50 11212.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 69 111.00 8325.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 59 97.50 7312.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 95 169.00 9379.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 81 99.50 7425.00 74.62
Subtotal (Total Children Is Unduplicated) 193 744.50 51499.45 69.17
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 6 32.00 800.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 90 625.25 31262.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 90 277.00 18802.76 67.88
OCCT-97530HM-OT SESSION BY OT ASST 15 20.75 1127.14 54.32
PHY-97110-PT SESSION BY LICENSED PT 177 570.25 38708.57 67.88
SENS-V5264-EARMOLD 1 2.00 37.44 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 167 544.00 36926.72 67.88
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 6 13.50 733.32 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 2 1.75 23.10 13.20
Subtotal (Total Children Is Unduplicated) 353 2086.50 128421.55 61.55
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Total 6863.00 329058.75 47.95
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Number of Children (Unduplicated) With at Least One Service 1038
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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 6251 3984.25 148869.75 0.00
P 596 809.25 53018.75 53071.50
D 75 59.50 2752.50 2752.50
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
1081 2008.25 124353.00 0.00
Other 0 0.00 0.00 0.00
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Total 8005 6863.00 329058.75 55824.00