CMS/EIP Fiscal Report Center: 03
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 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 469 205.75 7612.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 533 661.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 202 193.25 7150.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 676 1716.50 63510.50 37.00
TCON-TCON-TRANSITION CONFERENCE 159 161.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1034 2937.50 78273.50 26.65
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Screening, Eval, and Assessment,Class #02
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 3 3.00 48.90 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 13 13.00 114.79 8.83
AUDE-92557-COMP AUDIO THRESHOLD EVAL/SPCH RECOG 1 1.00 27.10 27.10
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 10 10.00 108.00 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 11 11.00 239.69 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.00 28.28 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.00 31.81 31.81
AUDE-V5090-DISPENSING FEE PER HEARING AID 2 4.00 460.00 115.00
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 1 2.00 111.00 55.50
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 11 20.00 1500.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.00 300.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 5.50 412.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 13 23.50 1304.25 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 2 4.00 222.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 122 219.50 16462.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 33 61.50 4583.25 74.52
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 14.50 1087.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 161 290.00 16081.13 55.45
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 6.00 450.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 11 11.00 412.87 37.53
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 5 5.00 242.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 2 2.00 56.29 28.15
PSTH-97001-EVAL BY LICENSED PT, INITIAL 8 8.00 348.81 43.60
SCREEN-T1023-INTERDISCIPLINARY SCREENING 172 173.00 8650.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 35 36.00 1681.65 46.71
Subtotal (Total Children Is Unduplicated) 360 929.50 54964.82 59.13
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 109 175.00 6212.50 35.50
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 4 5.25 118.75 22.62
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 47 93.00 4600.00 49.46
CONIP-CONIP-CONSULT, ITDS, PHONE 11 11.00 262.50 23.86
CONOF-CONOF-CONSULT, OT, FACE TO FACE 13 39.00 1950.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 1 1.50 37.50 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 16 27.75 1387.50 50.00
CONPP-CONPP-CONSULT, PT, PHONE 3 1.25 31.25 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 43 103.00 5125.00 49.76
CONSP-CONSP-CONSULT, SLP, PHONE 3 3.00 62.50 20.83
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 158 1244.50 57250.00 46.00
INTR-INTR-INTERPRETER 7 137.00 2085.00 15.22
OCCT-97530-OT SESSION BY LICENSED OT 64 299.25 16605.52 55.49
PHY-97110-PT SESSION BY LICENSED PT 57 198.00 11105.25 56.09
SENS-V5050-MED HEARING AID - ANALOG/DIGITAL 2 4.00 912.00 228.00
SENS-V5264-EARMOLD 2 4.00 72.00 18.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 143 656.50 36861.71 56.15
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 371 64475.0 32140.65 0.50
Subtotal (Total Children Is Unduplicated) 484 67478.0 176819.63 2.62
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Total 71345.00 310057.95 4.35
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Number of Children (Unduplicated) With at Least One Service 1148
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Center 03
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 3693 47192.25 137020.55 137020.55
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 4254 21363.25 119783.37 119783.37
2065 2787.50 53223.41 0.00
Other 2 2.00 30.62 0.00
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Total 10014 71345.00 310057.95 256803.92