CMS/EIP Fiscal Report Center: 10
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 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 52 30.50 1128.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 2185 3377.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 2624 4048.75 149803.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 4762 36450.0 1348406.25 36.99
TCON-TCON-TRANSITION CONFERENCE 704 706.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 4765 44612.3 1499338.50 33.61
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 104 114.00 1225.76 10.75
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 4 4.00 49.94 12.49
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 108 122.00 996.00 8.16
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 116 133.00 1320.14 9.93
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.00 8.44 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 111 125.00 2395.92 19.17
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 2 2.00 97.44 48.72
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 92 103.25 2655.07 25.71
AUDE-V5010-ASSESSMENT FOR HEARING AID 4 4.00 185.40 46.35
AUDE-V5090-DISPENSING FEE PER HEARING AID 6 11.00 962.71 87.52
EVAL-EVAL-DEVELOPMENTAL EVALUATION 19 27.50 1375.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 184 297.50 22312.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 83 124.00 9300.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 101 153.50 11512.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 62 105.50 7912.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 191 336.50 18675.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1115 1860.00 139500.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 684 1124.00 84262.50 74.97
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 690 1012.00 75900.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1236 2116.50 117465.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 759 1003.00 75187.50 74.96
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 2.00 97.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 2262 8782.25 573446.32 65.30
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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 393 717.75 35867.50 49.97
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 7 3.75 93.75 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 3 2.50 125.00 50.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 116 151.50 7575.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 8 2.75 68.75 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 16 18.00 900.00 50.00
CONPP-CONPP-CONSULT, PT, PHONE 1 0.50 12.50 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 156 149.25 7462.50 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 8 3.75 93.75 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 60 577.75 14443.75 25.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 24 121.00 5832.50 48.20
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 460 9593.00 460685.00 48.02
HERN-EIIF_NM-EI HEARING SERVICES AFTER SHINE NONMED 13 97.50 4875.00 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 14 127.25 6362.50 50.00
INTR-INTR-INTERPRETER 3 9.00 450.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 487 5041.25 330997.92 65.66
OCCT-97530HM-OT SESSION BY OT ASST 54 303.50 16114.93 53.10
PHY-97110-PT SESSION BY LICENSED PT 616 6727.50 445562.17 66.23
PHY-97110HM-PT SESSION BY PT ASST 2 2.50 135.80 54.32
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 16.00 268.76 16.80
SHIN-EIIF_NM-INITIAL SHINE SERVICES, IND NONMED 6 27.25 1362.50 50.00
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 13 67.50 3375.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 967 10298.8 695693.96 67.55
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 35 239.25 13008.22 54.37
SPL-92508-GROUP SPL SESSION PER CHILD 6 6.75 89.10 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 813 453021 226500.50 0.50
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 24 287.00 14350.00 50.00
Subtotal (Total Children Is Unduplicated) 1533 487838 2322852.55 4.76
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Total 541232.00 4395637.37 8.12
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Number of Children (Unduplicated) With at Least One Service 4771
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Center 10
Flag Claims Units Chgs Paid
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R 5 1.75 64.75 0.00
U 0 0.00 0.00 0.00
B 23171 15938.00 627480.63 153.00
P 23578 354252.75 1612833.97 1615804.10
D 711 531.50 22361.25 22406.75
S 186 117.75 4709.47 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
46227 170385.50 2128011.55 0.00
Other 3 4.75 175.75 92.50
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Total 93881 541232.00 4395637.37 1638456.35