CMS/EIP Fiscal Report Center: 07
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 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 1057 893.75 33041.00 36.97
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 393 414.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 596 833.50 30830.25 36.99
TCM-T1017TL-TARGETED CASE MANAGEMENT 1577 5111.00 188832.00 36.95
TCON-TCON-TRANSITION CONFERENCE 55 55.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1646 7307.25 252703.25 34.58
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.00 10.62 10.62
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 10 11.00 97.13 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 11 13.00 140.40 10.80
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.00 8.44 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 9 10.00 217.90 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.00 54.38 54.38
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 3 3.00 95.43 31.81
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.00 212.00 106.00
EVAL-EVAL-DEVELOPMENTAL EVALUATION 3 8.00 301.00 37.63
EXIT-EXIT-TRANSITION ASSESSMENT 11 28.50 1425.00 50.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 5.00 375.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 8 18.50 1387.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 8.50 471.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 35 55.00 4125.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 13 21.00 1575.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 10 12.50 937.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 137 265.00 14672.75 55.37
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 248 712.00 53250.00 74.79
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 5 5.00 363.90 72.78
NUTR-97802-NUTRITIONAL EVAL, INITIAL 1 1.00 50.00 50.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 4 4.00 194.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 31 31.00 1503.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 11 11.00 503.50 45.77
SCREEN-T1023-INTERDISCIPLINARY SCREENING 37 37.00 1850.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 61 61.00 2909.04 47.69
Subtotal (Total Children Is Unduplicated) 443 1327.00 86779.24 65.40
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.00 736.76 368.38
AUD-92630-AUD REHAB PRELING HEARING LOSS 1 4.00 275.44 68.86
AUD-HA_FUP-AUDIOLOGY SERVICES 4 6.00 300.00 50.00
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 17 20.00 850.00 42.50
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 2 1.25 31.25 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 6 4.50 225.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 3 2.25 56.25 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 12 18.75 937.50 50.00
CONOP-CONOP-CONSULT, OT, PHONE 11 8.25 206.25 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 16 24.75 1237.50 50.00
CONPP-CONPP-CONSULT, PT, PHONE 1 0.50 12.50 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 20 23.00 1150.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 8 4.75 93.75 19.74
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 3 18.50 925.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 475 3000.75 149937.50 49.97
OCCT-97530-OT SESSION BY LICENSED OT 106 570.75 35747.53 62.63
OCCT-97530HM-OT SESSION BY OT ASST 1 2.00 108.64 54.32
PHY-97110-PT SESSION BY LICENSED PT 75 453.25 29831.99 65.82
PHY-97110HM-PT SESSION BY PT ASST 1 5.00 271.60 54.32
SENS-FM-FM RECEIVER HEARING AID 2 2.00 2989.75 1494.88
SENS-V5264-EARMOLD 4 8.00 144.76 18.10
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 323 1891.00 127232.34 67.28
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 572 106118 53059.00 0.50
Subtotal (Total Children Is Unduplicated) 917 112189 406360.31 3.62
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Total 120823.50 745842.80 6.17
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Number of Children (Unduplicated) With at Least One Service 1725
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Center 07
Flag Claims Units Chgs Paid
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R 21 26.75 1502.75 0.00
U 0 0.00 0.00 0.00
B 3707 2585.25 104394.31 0.00
P 3256 103619.00 324732.13 324732.13
D 0 0.00 0.00 0.00
S 207 117.25 4451.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
9552 14475.25 310762.36 0.00
Other 0 0.00 0.00 0.00
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Total 16743 120823.50 745842.80 324732.13