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: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 1128 3687.50 136437.50 37.00
TCON-TCON-TRANSITION CONFERENCE 196 197.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1800 5779.25 173095.25 29.95
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 20 21.00 223.02 10.62
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 20 21.00 185.43 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 21 22.00 228.36 10.38
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 21 22.00 479.38 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 16 17.00 480.76 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 2 4.00 300.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 7 13.50 1012.50 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 6 11.50 638.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 31 46.00 3450.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 46 81.50 6112.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 19 34.50 2587.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 64 114.00 6327.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 38 44.50 3337.50 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) 129 473.50 26572.13 56.12
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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 300 1347.00 90011.91 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) 690 110270 301158.15 2.73
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Total 116522.25 500825.53 4.30
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Number of Children (Unduplicated) With at Least One Service 1942
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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 3876 110391.50 303815.03 303815.03
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
8194 6108.75 196101.50 0.00
Other 0 0.00 0.00 0.00
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Total 12111 116522.25 500825.53 304714.78