CMS/EIP Fiscal Report Center: 10
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 15 10.25 379.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 802 904.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 894 980.50 36278.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 2414 8472.50 313482.50 37.00
TCON-TCON-TRANSITION CONFERENCE 196 197.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 2421 10564.3 350140.25 33.14
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 21 22.00 233.64 10.62
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.00 16.30 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 21 23.00 203.09 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 22 24.00 249.12 10.38
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 22 24.00 522.96 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 17 19.00 537.32 28.28
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.00 46.80 46.80
AUDE-V5090-DISPENSING FEE PER HEARING AID 2 6.00 478.40 79.73
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 24 43.00 3225.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 19 33.50 2512.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 16 28.00 2100.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 8 13.50 1012.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 31 57.50 3191.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 259 435.50 32662.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 204 349.00 26175.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 144 243.00 18225.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 367 666.00 36963.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 179 212.50 15937.50 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 18 20.00 921.50 46.08
PSTH-97001-EVAL BY LICENSED PT, INITIAL 6 6.00 291.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 20 22.00 1018.50 46.30
Subtotal (Total Children Is Unduplicated) 638 2249.50 146522.88 65.14
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 4 27.00 2223.26 82.34
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 28 113.00 2825.00 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 259 2786.00 139300.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 258 1252.50 81986.52 65.46
OCCT-97530HM-OT SESSION BY OT ASST 16 46.00 2498.16 54.31
PHY-97110-PT SESSION BY LICENSED PT 395 1568.00 102213.24 65.19
PHY-97110HM-PT SESSION BY PT ASST 1 0.50 27.16 54.32
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 553 2403.75 161372.63 67.13
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 20 53.00 2851.80 53.81
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 500 105970 52985.00 0.50
Subtotal (Total Children Is Unduplicated) 929 114393 558501.40 4.88
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Total 127206.50 1055164.53 8.29
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Number of Children (Unduplicated) With at Least One Service 2470
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Center 10
Flag Claims Units Chgs Paid
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R 684 438.00 17217.75 0.00
U 0 0.00 0.00 0.00
B 6743 4507.50 180490.75 0.00
P 4580 111169.25 349482.78 349427.28
D 41 22.00 909.00 899.75
S 128 69.25 2562.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
10758 11000.50 504502.00 0.00
Other 0 0.00 0.00 0.00
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Total 22934 127206.50 1055164.53 350327.03