CMS/EIP Fiscal Report Center: 03
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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 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 618 1769.50 65471.50 37.00
TCON-TCON-TRANSITION CONFERENCE 143 143.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1120 3378.50 90409.50 26.76
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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-92555-SPEECH AUD THRESHOLD (DETECTION) 6 6.00 52.98 8.83
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 5 5.00 108.95 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.00 28.28 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 7 8.50 637.50 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 11 16.50 915.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 69 109.50 8212.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 51 99.00 7425.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 150 268.50 14901.75 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 24 25.00 1250.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 34 34.00 1605.48 47.22
Subtotal (Total Children Is Unduplicated) 314 736.50 43321.34 58.82
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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 76 171.50 6100.00 35.57
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 181 1259.25 62422.50 49.57
INTR-INTR-INTERPRETER 13 181.00 9552.50 52.78
OCCT-97530-OT SESSION BY LICENSED OT 70 476.50 27907.82 58.57
PHY-97110-PT SESSION BY LICENSED PT 65 414.75 26345.08 63.52
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 142 988.00 60070.99 60.80
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) 558 101543 264623.33 2.61
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Total 105657.50 398354.17 3.77
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Number of Children (Unduplicated) With at Least One Service 1204
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Center 03
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 2302 33977.25 88742.05 88742.05
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
6455 68898.00 222413.54 0.00
Other 4 4.00 61.24 0.00
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Total 12799 105657.50 398354.17 175879.39