CMS/EIP Fiscal Report Center: 10
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 6 2.25 83.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 772 874.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 895 1035.50 38313.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 2378 8976.25 332121.25 37.00
TCON-TCON-TRANSITION CONFERENCE 218 218.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 2381 11106.0 370518.00 33.36
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 18 18.00 191.16 10.62
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 3 3.00 47.14 15.71
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 20 21.00 184.53 8.79
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 20 21.00 217.98 10.38
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 20 21.00 452.80 21.56
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 13 14.00 395.92 28.28
AUDE-V5090-DISPENSING FEE PER HEARING AID 2 4.00 478.40 119.60
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 25 43.50 3262.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 23 44.50 3337.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 19 32.50 2437.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 6 9.50 712.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 37 72.50 4023.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 307 530.50 39787.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 187 321.50 24112.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 159 253.50 19012.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 311 582.50 32328.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 177 245.50 18412.50 75.00
Subtotal (Total Children Is Unduplicated) 524 2238.00 149395.43 66.75
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 6 26.00 3172.78 122.03
AUD-HA_FUP-AUDIOLOGY SERVICES 4 4.00 174.69 43.67
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 145 177.75 8887.50 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 2 1.75 43.75 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 28 28.75 1437.50 50.00
CONOP-CONOP-CONSULT, OT, PHONE 11 3.00 75.00 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 45 34.00 1700.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 5 1.50 37.50 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 27 172.75 4318.75 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 240 2544.50 123545.00 48.55
INTR-INTR-INTERPRETER 1 2.00 100.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 220 864.50 56984.83 65.92
OCCT-97530HM-OT SESSION BY OT ASST 30 77.00 4031.12 52.35
PHY-97110-PT SESSION BY LICENSED PT 290 1167.25 77281.16 66.21
PHY-97110HM-PT SESSION BY PT ASST 4 5.50 298.76 54.32
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 2.00 474.24 237.12
SENS-V5264-EARMOLD 3 6.00 112.32 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 438 1810.00 122217.67 67.52
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 16 65.50 3557.96 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 2 8.50 112.20 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 420 91720.0 45860.00 0.50
Subtotal (Total Children Is Unduplicated) 760 98724.3 455422.73 4.61
----------------------------------------------------------------------------------------------------------------
Total 112068.25 975336.16 8.70
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 2401
----------------------------------------------------------------------------------------------------------------
Center 10
Flag Claims Units Chgs Paid
-------------------------------------------------
R 66 48.50 1794.50 0.00
U 0 0.00 0.00 0.00
B 4521 3110.25 120428.25 83.25
P 6535 98050.00 402543.11 402543.11
D 41 19.75 730.75 730.75
S 289 169.50 7113.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
11006 10670.25 442726.30 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 22458 112068.25 975336.16 403357.11