CMS/EIP Fiscal Report Center: 10
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 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 1271 4505.25 166694.25 37.00
TCON-TCON-TRANSITION CONFERENCE 218 218.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1849 6635.00 205091.00 30.91
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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 7 12.50 937.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 9.00 675.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 9.00 675.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 8 15.50 860.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 56 98.00 7350.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 47 81.00 6075.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 25 43.00 3225.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 62 115.50 6410.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 41 56.50 4237.50 75.00
Subtotal (Total Children Is Unduplicated) 123 542.00 32413.43 59.80
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 5 24.00 2493.86 103.91
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 20 129.75 3243.75 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 141 1764.25 84532.50 47.91
INTR-INTR-INTERPRETER 1 2.00 100.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 127 484.75 31309.10 64.59
OCCT-97530HM-OT SESSION BY OT ASST 18 48.50 2483.00 51.20
PHY-97110-PT SESSION BY LICENSED PT 153 552.75 35568.90 64.35
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 288 1238.00 83418.31 67.38
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 16 63.50 3449.32 54.32
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 420 91720.0 45860.00 0.50
Subtotal (Total Children Is Unduplicated) 655 96288.3 306401.24 3.18
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Total 103465.25 543905.67 5.26
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Number of Children (Unduplicated) With at Least One Service 1948
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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 1 0.25 9.25 0.00
P 3918 96039.50 306121.86 306121.86
D 37 16.75 619.75 619.75
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
9396 7408.75 237154.81 0.00
Other 0 0.00 0.00 0.00
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Total 13352 103465.25 543905.67 306741.61