CMS/EIP Fiscal Report Center: 10
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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 10 8.00 296.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 800 902.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 733 819.50 30321.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 964 3071.50 113645.50 37.00
TCON-TCON-TRANSITION CONFERENCE 196 197.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1558 4998.00 144263.00 28.86
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 15 16.00 169.92 10.62
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 15 16.00 141.28 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 16 17.00 176.46 10.38
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 16 17.00 370.43 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 13 14.00 395.92 28.28
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.00 46.80 46.80
AUDE-V5090-DISPENSING FEE PER HEARING AID 2 4.00 378.17 94.54
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.00 150.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 10.00 750.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.00 150.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 10.00 555.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 23 35.00 2625.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 23 43.50 3262.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 13 23.50 1762.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 31 59.00 3274.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 20 27.00 2025.00 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 6 6.00 281.96 46.99
SPCH-92506-SPEECH EVAL BY LICENSED SLP 8 8.00 353.00 44.13
Subtotal (Total Children Is Unduplicated) 84 311.00 16868.44 54.24
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 4 17.00 1035.34 60.90
AUD-HA_FUP-AUDIOLOGY SERVICES 2 2.00 100.00 50.00
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 107 108.75 5437.50 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 2 0.50 12.50 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 4 4.00 200.00 50.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 14 12.00 600.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 3 0.75 18.75 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 0.50 25.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 19 18.50 925.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 6 3.00 75.00 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 18 79.00 1975.00 25.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 3 15.00 750.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 146 1703.75 85187.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 97 466.00 28935.11 62.09
OCCT-97530HM-OT SESSION BY OT ASST 9 31.00 1683.92 54.32
PHY-97110-PT SESSION BY LICENSED PT 118 448.25 27276.27 60.85
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 2 4.00 2000.00 500.00
SENS-V5264-EARMOLD 2 4.00 74.88 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 299 1345.50 89910.09 66.82
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 14 34.50 1849.47 53.61
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 500 105970 52985.00 0.50
Subtotal (Total Children Is Unduplicated) 689 110268 301056.33 2.73
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Total 115577.00 462187.77 4.00
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Number of Children (Unduplicated) With at Least One Service 1691
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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 0 0.00 0.00 0.00
P 3852 110367.00 303370.27 303370.27
D 41 22.00 909.00 899.75
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
7221 5188.00 157908.50 0.00
Other 0 0.00 0.00 0.00
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Total 11114 115577.00 462187.77 304270.02