CMS/EIP Fiscal Report Center: 09
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 1106 958.25 35436.75 36.98
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 824 1044.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 831 853.25 31570.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1946 5456.75 201761.00 36.97
TCON-TCON-TRANSITION CONFERENCE 200 200.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 2067 8512.25 268768.00 31.57
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.00 8.83 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.00 0.54 0.54
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.00 6.01 6.01
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 1.00 119.60 119.60
EXIT-EXIT-TRANSITION ASSESSMENT 62 102.50 5125.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 68 105.00 7875.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 8 13.50 1012.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 28 35.00 2625.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 27 48.50 3637.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 27 38.00 2109.00 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 15 15.00 832.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 401 599.00 44925.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 73 126.00 9450.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 205 276.50 20638.50 74.64
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 251 389.00 21589.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 80 111.50 8362.50 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 2 3.00 145.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 6 6.00 291.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.00 48.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 3 3.00 150.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 3.00 145.50 48.50
Subtotal (Total Children Is Unduplicated) 630 1879.50 129097.48 68.69
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 7.00 1282.98 183.28
AUD-HA_FUP-AUDIOLOGY SERVICES 1 2.00 82.00 41.00
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 124 164.75 8237.50 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 5 2.50 62.50 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 12 18.50 925.00 50.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 42 52.75 2637.50 50.00
CONOP-CONOP-CONSULT, OT, PHONE 2 0.75 18.75 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 12 45.25 2262.50 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 27 97.00 4850.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 438 3287.25 164302.50 49.98
INTR-INTR-INTERPRETER 13 24.00 1200.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 390 2764.00 185531.92 67.12
OCCT-97530HM-OT SESSION BY OT ASST 4 15.50 654.06 42.20
PHY-97110-PT SESSION BY LICENSED PT 353 2171.00 145487.47 67.01
PHY-97110HM-PT SESSION BY PT ASST 15 70.75 3838.75 54.26
SENS-HA_INS-SENSORY AID INSURANCE PER EAR 2 4.00 260.00 65.00
SENS-V5264-EARMOLD 2 4.00 74.88 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 710 5113.25 345546.11 67.58
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 856 231467 115733.50 0.50
Subtotal (Total Children Is Unduplicated) 1286 245311 982987.92 4.01
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Total 255703.00 1380853.40 5.40
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Number of Children (Unduplicated) With at Least One Service 2213
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Center 09
Flag Claims Units Chgs Paid
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R 117 85.75 3388.25 0.00
U 0 0.00 0.00 0.00
B 3161 2721.75 127309.91 46.25
P 10133 154948.75 530888.42 615783.49
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 5176 81795.00 276694.23 276694.23
4323 16151.75 442572.59 412.49
Other 0 0.00 0.00 0.00
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Total 22910 255703.00 1380853.40 892936.46