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: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 1123 4129.00 152773.00 37.00
TCON-TCON-TRANSITION CONFERENCE 170 170.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1714 6107.50 190198.50 31.14
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 18 19.00 200.39 10.55
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 2 2.00 17.34 8.67
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 24 27.00 182.56 6.76
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 27 32.00 276.26 8.63
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.00 8.44 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 26 29.00 502.94 17.34
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 20 21.25 480.01 22.59
AUDE-V5090-DISPENSING FEE PER HEARING AID 2 2.00 124.20 62.10
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 11.50 862.50 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 2 4.00 300.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 10.50 582.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 67 112.00 8400.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 42 66.50 4987.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 31 44.50 3337.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 54 94.00 5217.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 39 47.00 3525.00 75.00
Subtotal (Total Children Is Unduplicated) 135 526.25 29229.39 55.54
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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 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 162 623.75 40529.84 64.98
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 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) 668 101275 308427.54 3.05
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Total 107909.00 527855.43 4.89
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Number of Children (Unduplicated) With at Least One Service 1824
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Center 10
Flag Claims Units Chgs Paid
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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 3748 86849.25 290089.30 290089.30
D 22 25.25 1397.25 1397.25
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
8693 21024.75 236008.13 0.00
Other 0 0.00 0.00 0.00
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Total 12482 107909.00 527855.43 291486.55