CMS/EIP Fiscal Report Center: 07
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 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 1085 861.00 31857.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 390 405.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 619 906.50 33540.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 941 2569.25 95043.75 36.99
TCON-TCON-TRANSITION CONFERENCE 44 44.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1579 4785.75 160441.25 33.52
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 3 3.00 26.49 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 4 4.00 43.20 10.80
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 2 2.00 16.88 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 3 3.00 65.37 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 2 2.00 108.76 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.00 28.28 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 3 3.00 95.43 31.81
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.00 46.80 46.80
AUDE-V5090-DISPENSING FEE PER HEARING AID 2 3.00 318.00 106.00
EXIT-EXIT-TRANSITION ASSESSMENT 21 40.50 2025.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 5.50 412.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.00 150.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 10.50 787.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.50 194.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 30 46.50 3487.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 14 26.00 1932.50 74.33
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 8.00 600.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 91 166.50 9240.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 109 290.50 21637.50 74.48
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 4 4.00 291.12 72.78
NUTR-97802-NUTRITIONAL EVAL, INITIAL 3 1.50 75.00 50.00
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 1 0.25 12.50 50.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 5 5.00 177.89 35.58
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 15 15.00 646.18 43.08
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 22 23.00 1056.74 45.95
SCREEN-T1023-INTERDISCIPLINARY SCREENING 22 23.00 1150.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 45 44.00 2134.00 48.50
Subtotal (Total Children Is Unduplicated) 282 738.25 46808.64 63.40
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EI Services,Class #03
AUD-HA_FUP-AUDIOLOGY SERVICES 3 3.00 150.00 50.00
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 31 36.00 1650.00 45.83
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 2 0.75 18.75 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 9 15.00 750.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 3 1.00 25.00 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 19 30.75 1537.50 50.00
CONOP-CONOP-CONSULT, OT, PHONE 9 5.50 137.50 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 18 19.00 950.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 21 26.50 1325.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 11 6.25 156.25 25.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 2 17.00 850.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 257 1635.25 81762.50 50.00
INTR-INTR-INTERPRETER 1 4.50 225.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 81 541.75 33772.36 62.34
PHY-97110-PT SESSION BY LICENSED PT 66 358.25 22773.78 63.57
SENS-FM-FM RECEIVER HEARING AID 1 1.00 1267.00 1267.00
SENS-V5050-MED HEARING AID - ANALOG/DIGITAL 1 2.00 474.24 237.12
SENS-V5264-EARMOLD 3 4.00 74.88 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 273 1897.25 125470.22 66.13
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 669 119916 59941.50 0.50
Subtotal (Total Children Is Unduplicated) 944 124521 333311.48 2.68
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Total 130044.75 540561.37 4.16
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Number of Children (Unduplicated) With at Least One Service 1705
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Center 07
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 3366 119417.50 345279.56 345279.56
D 0 0.00 0.00 0.00
S 20 13.00 481.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
8913 10614.25 194800.81 0.00
Other 0 0.00 0.00 0.00
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Total 12299 130044.75 540561.37 345279.56