CMS/EIP Fiscal Report Center: 06
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 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 570 310.25 11479.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 621 654.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 448 418.25 15475.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1048 2988.50 110574.50 37.00
TCON-TCON-TRANSITION CONFERENCE 220 227.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1493 4598.00 137529.00 29.91
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 9 9.00 79.47 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 8 8.00 86.40 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 8 8.00 174.32 21.79
EXIT-EXIT-TRANSITION ASSESSMENT 2 2.00 100.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.50 112.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.50 112.50 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 23 35.50 2662.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 20 30.00 2250.00 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 5.00 375.00 75.00
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 2 2.00 54.44 27.22
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 2 2.00 114.54 57.27
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 31 106.50 6218.67 58.39
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 6 6.00 1252.70 208.78
AUD-HA_FUP-AUDIOLOGY SERVICES 1 1.00 50.00 50.00
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 26 26.00 780.00 30.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 3 1.75 26.25 15.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 4 6.00 180.00 30.00
CONIP-CONIP-CONSULT, ITDS, PHONE 1 1.00 15.00 15.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 8 10.00 332.50 33.25
CONOP-CONOP-CONSULT, OT, PHONE 1 0.50 7.50 15.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 7 6.25 168.75 27.00
CONPP-CONPP-CONSULT, PT, PHONE 3 1.25 20.75 16.60
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 6 8.00 210.00 26.25
CONSP-CONSP-CONSULT, SLP, PHONE 4 2.50 42.50 17.00
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 3 95.00 4750.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 174 1412.25 65612.50 46.46
INTR-INTR-INTERPRETER 16 59.75 3451.00 57.76
OCCT-97530-OT SESSION BY LICENSED OT 95 406.00 23590.45 58.10
OCCT-97530HM-OT SESSION BY OT ASST 9 35.75 1941.94 54.32
PHY-97110-PT SESSION BY LICENSED PT 127 669.00 42675.38 63.79
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 410 2502.75 161892.45 64.69
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 726 164300 81044.50 0.49
Subtotal (Total Children Is Unduplicated) 861 169551 388044.17 2.29
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Total 174255.25 531791.84 3.05
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Number of Children (Unduplicated) With at Least One Service 1620
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Center 06
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 10550 130073.50 294876.93 294876.93
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 0 0.00 0.00 0.00
10330 44181.75 236914.91 157.25
Other 0 0.00 0.00 0.00
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Total 20880 174255.25 531791.84 295034.18