CMS/EIP Fiscal Report Center: 10
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Agency Filter:EXT
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
Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 71 79.00 849.10 10.75
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 4 4.00 49.94 12.49
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 76 86.00 689.78 8.02
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 86 99.00 969.19 9.79
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.00 8.44 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 86 98.00 1845.93 18.84
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 2 2.00 97.44 48.72
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 71 80.25 2051.60 25.57
AUDE-V5010-ASSESSMENT FOR HEARING AID 4 4.00 185.40 46.35
AUDE-V5090-DISPENSING FEE PER HEARING AID 6 10.00 843.11 84.31
Subtotal (Total Children Is Unduplicated) 104 463.25 7589.93 16.38
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 40 185.00 24833.27 134.23
AUD-HA_FUP-AUDIOLOGY SERVICES 15 24.00 1153.34 48.06
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 364 633.75 31667.50 49.97
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 7 3.75 93.75 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 2 2.00 100.00 50.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 66 72.50 3625.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 8 2.75 68.75 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 7 6.00 300.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 94 108.00 5400.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 7 3.50 87.50 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 47 459.75 11493.75 25.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 40.00 1782.50 44.56
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 214 4830.75 222572.50 46.07
INTR-INTR-INTERPRETER 3 9.00 450.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 276 2455.00 155602.60 63.38
OCCT-97530HM-OT SESSION BY OT ASST 34 170.25 8876.79 52.14
PHY-97110-PT SESSION BY LICENSED PT 314 2829.75 180989.64 63.96
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 6 11.00 4355.46 395.95
SENS-HA_INS-SENSORY AID INSURANCE PER EAR 2 3.00 195.00 65.00
SENS-V5050-MED HEARING AID - ANALOG/DIGITAL 1 1.00 9.12 9.12
SENS-V5264-EARMOLD 6 14.00 231.32 16.52
SHIN-EIIF_NM-INITIAL SHINE SERVICES, IND NONMED 3 5.75 287.50 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 645 6032.25 406357.34 67.36
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 21 141.00 7630.60 54.12
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 701 328233 164106.50 0.50
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 18 105.25 5262.50 50.00
Subtotal (Total Children Is Unduplicated) 1191 346382 1237532.23 3.57
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Total 346845.25 1245122.16 3.59
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Number of Children (Unduplicated) With at Least One Service 1215
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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 0 0.00 0.00 0.00
P 15163 346845.25 1245122.16 1245122.16
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
0 0.00 0.00 0.00
Other 0 0.00 0.00 0.00
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Total 15163 346845.25 1245122.16 1245122.16