CMS/EIP Fiscal Report Center: 03
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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 810 477.75 17676.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 623 792.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 181 196.25 7261.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1239 3594.75 133005.75 37.00
TCON-TCON-TRANSITION CONFERENCE 143 143.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1297 5203.75 157943.75 30.35
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.00 10.62 10.62
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 3 3.00 48.90 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 57 57.00 503.31 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 22 22.00 237.60 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 54 54.00 1176.66 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.00 54.38 54.38
AUDE-92586-AUD EVOKED RESPONSE (SCREEN) 2 2.00 60.86 30.43
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 7 7.00 197.96 28.28
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 1.00 115.00 115.00
EXIT-EXIT-TRANSITION ASSESSMENT 67 105.50 5275.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 9 11.00 825.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 6.00 450.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 14 20.00 1110.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 98 153.00 11475.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 62 120.00 9000.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 219 387.00 21478.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.00 150.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 10 10.00 365.69 36.57
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 13 13.00 630.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 8 8.00 388.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 17 17.00 798.34 46.96
SCREEN-T1023-INTERDISCIPLINARY SCREENING 30 31.00 1550.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 34 34.00 1605.48 47.22
Subtotal (Total Children Is Unduplicated) 409 1065.50 57506.80 53.97
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 3 3.00 963.15 321.05
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 154 213.00 9425.00 44.25
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 2 2.00 31.25 15.63
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 77 172.50 6150.00 35.65
CONIP-CONIP-CONSULT, ITDS, PHONE 10 5.75 125.00 21.74
CONOF-CONOF-CONSULT, OT, FACE TO FACE 37 61.75 3087.50 50.00
CONOP-CONOP-CONSULT, OT, PHONE 3 1.25 31.25 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 24 41.75 2050.00 49.10
CONPP-CONPP-CONSULT, PT, PHONE 2 1.25 31.25 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 88 136.25 6812.50 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 1 0.50 12.50 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 187 1296.25 64072.50 49.43
INTR-INTR-INTERPRETER 13 181.00 9552.50 52.78
OCCT-97530-OT SESSION BY LICENSED OT 70 480.00 28145.40 58.64
PHY-97110-PT SESSION BY LICENSED PT 67 419.25 26650.54 63.57
SENS-V5050-MED HEARING AID - ANALOG/DIGITAL 1 2.00 798.00 399.00
SENS-V5264-EARMOLD 2 4.00 72.00 18.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 142 991.00 60274.63 60.82
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 2.00 12.94 6.47
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 479 97577.0 48772.10 0.50
Subtotal (Total Children Is Unduplicated) 560 101592 267070.01 2.63
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Total 107860.75 482520.56 4.47
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Number of Children (Unduplicated) With at Least One Service 1343
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Center 03
Flag Claims Units Chgs Paid
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R 51 46.00 1907.50 0.00
U 0 0.00 0.00 0.00
B 71 56.50 2185.00 0.00
P 4809 35814.25 161580.05 161555.30
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 4038 2778.25 87137.34 87137.34
6602 69027.75 227559.97 0.00
Other 138 138.00 2150.70 0.00
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Total 15709 107860.75 482520.56 248692.64