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: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 7 2.75 101.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 805 889.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 923 986.75 36466.50 36.96
TCM-T1017TL-TARGETED CASE MANAGEMENT 1215 4192.50 155122.50 37.00
TCON-TCON-TRANSITION CONFERENCE 245 245.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1855 6316.00 191690.75 30.35
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 35 35.00 371.70 10.62
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 2 2.00 32.60 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 36 36.00 316.98 8.81
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 38 38.00 392.96 10.34
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 39 39.00 834.57 21.40
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.00 54.38 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 25 25.00 707.00 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 59 108.50 8137.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 27 47.50 3562.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 29 50.00 3750.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 67 127.50 7076.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 35 46.00 3450.00 75.00
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 28.50 28.50
Subtotal (Total Children Is Unduplicated) 129 598.00 31670.84 52.96
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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 117362.75 573144.13 4.88
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Number of Children (Unduplicated) With at Least One Service 1993
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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 4364 110630.75 352973.63 352973.63
D 73 49.75 1840.75 1840.75
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
9084 6682.00 218320.50 0.00
Other 0 0.00 0.00 0.00
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Total 13522 117362.75 573144.13 354814.38