CMS/EIP Fiscal Report Center: 01
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 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 853 416.00 15392.00 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 863 961.75 35584.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 2458 7468.25 276242.00 36.99
Subtotal (Total Children Is Unduplicated) 2483 8846.00 327218.75 36.99
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 7 8.00 270.50 33.81
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 8 9.00 79.47 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 10 11.00 118.80 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 9 10.00 197.64 19.76
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.00 56.56 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 3 3.00 95.43 31.81
AUDE-92682-CONDITIONED PLAY AUDIOMETRY 1 1.00 21.34 21.34
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.00 239.20 119.60
EVAL-EVAL-DEVELOPMENTAL EVALUATION 6 12.25 612.50 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 84 172.75 8637.50 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 18 27.50 2062.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 7 9.00 675.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 23 35.00 1942.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 280 396.00 29700.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 33 52.00 3816.50 73.39
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 15 23.00 1725.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 295 424.50 23479.50 55.31
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 191 231.00 17295.75 74.87
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
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 7 7.00 302.44 43.21
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 3 3.00 145.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 3 3.00 154.21 51.40
SPCH-92506-SPEECH EVAL BY LICENSED SLP 17 16.50 784.50 47.55
Subtotal (Total Children Is Unduplicated) 641 1464.50 92767.33 63.34
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 10 59.00 14312.25 242.58
AUD-HA_FUP-AUDIOLOGY SERVICES 4 4.00 200.00 50.00
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 59 83.75 4187.50 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 9 2.25 56.25 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 17 13.00 650.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 4 2.75 68.75 25.00
CONOP-CONOP-CONSULT, OT, PHONE 1 0.25 6.25 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 13 10.00 500.00 50.00
CONPP-CONPP-CONSULT, PT, PHONE 3 2.50 62.50 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 25 14.75 737.50 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 15 9.25 231.25 25.00
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 10 24.00 720.00 30.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 47 245.00 7050.00 28.78
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 13 52.75 2637.50 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 59 304.50 15225.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 396 2168.50 108425.00 50.00
INTR-INTR-INTERPRETER 75 442.00 15110.00 34.19
OCCT-97530-OT SESSION BY LICENSED OT 79 461.75 31841.71 68.96
OCCT-97530HM-OT SESSION BY OT ASST 3 9.00 488.88 54.32
PHY-97110-PT SESSION BY LICENSED PT 123 653.00 44925.96 68.80
PHY-97110HM-PT SESSION BY PT ASST 9 45.00 2457.96 54.62
RSPT-RSPT-RESPITE 1 97.50 756.00 7.75
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 1 2.00 1000.00 500.00
SENS-V5264-EARMOLD 4 8.00 149.76 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 617 3771.50 258684.08 68.59
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 2 1.50 81.48 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 19 59.75 890.17 14.90
TRAN-TRAN-FAMILY TRANSPORTATION 1 60.00 6000.00 100.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1152 239150 119563.70 0.50
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 7 38.00 1900.00 50.00
Subtotal (Total Children Is Unduplicated) 1361 247795 638919.45 2.58
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Total 258105.75 1058905.53 4.10
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Number of Children (Unduplicated) With at Least One Service 2640
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Center 01
Flag Claims Units Chgs Paid
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R 109 123.25 7777.00 0.00
U 0 0.00 0.00 0.00
B 2448 1728.50 66954.25 0.00
P 8611 145100.50 323666.00 323665.50
D 216 260.50 17050.44 0.00
S 2290 4935.25 68995.25 0.00
H 23 32.50 1954.99 0.00
T 5727 94173.25 241092.13 241092.13
8325 7087.50 276887.17 11.88
Other 742 4664.50 54528.30 0.00
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Total 28491 258105.75 1058905.53 564769.51