CMS/EIP Fiscal Report Center: 01
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 Page: 1
Payclass Filters:TPIN
Eligibility Filter:Part C (excluding not eligible)
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 2 0.50 18.50 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 6 4.50 166.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 12 27.25 1008.25 37.00
Subtotal (Total Children Is Unduplicated) 19 32.25 1193.25 37.00
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Screening, Eval, and Assessment,Class #02
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.00 239.20 119.60
EVAL-EVAL-DEVELOPMENTAL EVALUATION 3 7.50 375.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 3 8.00 400.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 7.00 525.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.50 262.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 7.00 388.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 20 28.00 2100.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 25 34.50 1887.00 54.70
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 26 36.00 2670.75 74.19
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 2.00 114.54 57.27
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 2 3.00 150.45 50.15
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.00 90.00 90.00
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 2 2.00 97.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.00 105.71 52.86
SPCH-92506-SPEECH EVAL BY LICENSED SLP 3 1.50 123.50 82.33
Subtotal (Total Children Is Unduplicated) 69 145.00 9529.15 65.72
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 5 8.00 4149.69 518.71
AUD-HA_FUP-AUDIOLOGY SERVICES 2 2.00 100.00 50.00
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 6 9.00 450.00 50.00
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 3.00 150.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 10 37.00 1900.00 51.35
OCCT-97530-OT SESSION BY LICENSED OT 24 52.00 4733.51 91.03
PHY-97110-PT SESSION BY LICENSED PT 34 61.00 5455.87 89.44
PHY-97110HM-PT SESSION BY PT ASST 1 0.50 50.25 100.50
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 1 2.00 1000.00 500.00
SENS-V5264-EARMOLD 3 6.00 112.32 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 108 317.00 26747.72 84.38
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 5 255.00 127.50 0.50
Subtotal (Total Children Is Unduplicated) 165 752.50 44976.86 59.77
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Total 929.75 55699.26 59.91
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Number of Children (Unduplicated) With at Least One Service 231
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Center 01
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 0 0.00 0.00 0.00
D 93 121.00 7290.25 0.00
S 19 24.75 915.75 0.00
H 12 19.50 1152.49 0.00
T 0 0.00 0.00 0.00
364 294.25 27626.08 11.88
Other 215 470.25 18714.69 0.00
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Total 703 929.75 55699.26 11.88