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:Program Patients
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 36 18.00 666.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 717 797.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 834 993.50 36759.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 2295 8751.00 323740.75 36.99
TCON-TCON-TRANSITION CONFERENCE 170 170.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 2303 10729.5 361166.25 33.66
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 22 23.00 242.87 10.56
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 2 2.00 17.34 8.67
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 28 31.00 217.88 7.03
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 30 35.00 307.82 8.79
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.00 8.44 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 31 34.00 611.89 18.00
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 24 25.25 593.13 23.49
AUDE-V5090-DISPENSING FEE PER HEARING AID 2 3.00 243.80 81.27
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 44 73.00 5475.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 19 26.50 1987.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 16 23.00 1725.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 15 25.00 1875.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 36 66.00 3663.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 289 479.00 35925.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 191 316.00 23700.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 141 219.50 16462.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 262 461.50 25613.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 192 248.00 18562.50 74.85
Subtotal (Total Children Is Unduplicated) 531 2091.75 137231.92 65.61
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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 212 2036.00 97665.00 47.97
OCCT-97530-OT SESSION BY LICENSED OT 274 1161.25 77351.14 66.61
OCCT-97530HM-OT SESSION BY OT ASST 36 82.50 4390.19 53.21
PHY-97110-PT SESSION BY LICENSED PT 397 1567.00 104557.65 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 438 96820.0 48400.00 0.50
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 14 63.75 3187.50 50.00
Subtotal (Total Children Is Unduplicated) 902 104655 523971.32 5.01
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Total 117476.25 1022369.49 8.70
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Number of Children (Unduplicated) With at Least One Service 2327
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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 6940 4582.75 171494.00 0.00
P 4509 87904.75 359792.37 359743.30
D 114 104.75 5135.75 5135.75
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
10889 24882.25 485882.62 0.00
Other 0 0.00 0.00 0.00
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Total 22454 117476.25 1022369.49 364879.05