CMS/EIP Fiscal Report Center: 10
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 Page: 1
Payclass Filters:GR
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 5 1.75 64.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 804 888.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 772 838.25 30972.00 36.95
TCM-T1017TL-TARGETED CASE MANAGEMENT 1062 3623.75 134078.75 37.00
TCON-TCON-TRANSITION CONFERENCE 245 245.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1636 5596.75 165115.50 29.50
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 32 32.00 339.84 10.62
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 2 2.00 32.60 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 33 33.00 290.49 8.80
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 35 35.00 361.82 10.34
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 35 35.00 748.51 21.39
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.00 54.38 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 22 22.00 622.16 28.28
AUDE-V5010-ASSESSMENT FOR HEARING AID 2 2.00 93.60 46.80
AUDE-V5090-DISPENSING FEE PER HEARING AID 2 3.00 358.80 119.60
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 8.50 637.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 7.00 525.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 5.00 375.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.00 300.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 12.00 666.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 36 68.00 5100.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 18 32.50 2437.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 17 29.50 2212.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 33 63.50 3524.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 16 25.00 1875.00 75.00
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 28.50 28.50
Subtotal (Total Children Is Unduplicated) 85 421.00 20583.45 48.89
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 9 43.00 10402.98 241.93
AUD-HA_FUP-AUDIOLOGY SERVICES 2 3.00 96.07 32.02
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 124 130.50 6525.00 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 3 0.75 18.75 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 28 24.00 1200.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 6 2.00 50.00 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 41 33.50 1675.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 6 3.75 93.75 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 19 110.00 2750.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 154 1952.75 94437.50 48.36
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 19 39.75 1987.50 50.00
INTR-INTR-INTERPRETER 1 2.00 100.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 140 582.75 36817.58 63.18
OCCT-97530HM-OT SESSION BY OT ASST 11 30.50 1372.60 45.00
PHY-97110-PT SESSION BY LICENSED PT 142 541.00 34641.53 64.03
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 2 3.00 1500.00 500.00
SENS-V5264-EARMOLD 4 8.00 149.76 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 322 1451.75 97764.22 67.34
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 12 40.00 2172.80 54.32
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 482 105380 52690.00 0.50
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 22 66.75 3337.50 50.00
Subtotal (Total Children Is Unduplicated) 735 110449 349782.54 3.17
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Total 116466.50 535481.49 4.60
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Number of Children (Unduplicated) With at Least One Service 1765
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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 4348 110614.75 352713.24 352713.24
D 67 44.75 1655.75 1655.75
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
8202 5806.75 181103.25 0.00
Other 0 0.00 0.00 0.00
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Total 12618 116466.50 535481.49 354368.99