CMS/EIP Fiscal Report Center: 07
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 1057 893.50 33031.75 36.97
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 393 414.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 596 833.50 30830.25 36.99
TCM-T1017TL-TARGETED CASE MANAGEMENT 826 2487.50 91926.75 36.96
TCON-TCON-TRANSITION CONFERENCE 55 55.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1475 4683.50 155788.75 33.26
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.00 10.62 10.62
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 8 9.00 79.47 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 9 11.00 118.80 10.80
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.00 8.44 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 7 8.00 174.32 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.00 54.38 54.38
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 2 2.00 63.62 31.81
EVAL-EVAL-DEVELOPMENTAL EVALUATION 3 8.00 301.00 37.63
EXIT-EXIT-TRANSITION ASSESSMENT 11 28.50 1425.00 50.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 5.00 375.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 11.00 825.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 4.00 222.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 27 43.50 3262.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 11 17.00 1275.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 8.00 600.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 73 137.50 7624.25 55.45
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 126 355.50 26625.00 74.89
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 3 3.00 218.34 72.78
NUTR-97802-NUTRITIONAL EVAL, INITIAL 1 1.00 50.00 50.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 4 4.00 194.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 21 21.00 1018.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 9 9.00 406.50 45.17
SCREEN-T1023-INTERDISCIPLINARY SCREENING 17 17.00 850.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 46 46.00 2181.54 47.42
Subtotal (Total Children Is Unduplicated) 269 753.00 48011.78 63.76
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.00 736.76 368.38
AUD-92630-AUD REHAB PRELING HEARING LOSS 1 4.00 275.44 68.86
AUD-HA_FUP-AUDIOLOGY SERVICES 3 5.00 250.00 50.00
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 17 20.00 850.00 42.50
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 2 1.25 31.25 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 6 4.50 225.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 3 2.25 56.25 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 12 18.75 937.50 50.00
CONOP-CONOP-CONSULT, OT, PHONE 11 8.25 206.25 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 16 24.75 1237.50 50.00
CONPP-CONPP-CONSULT, PT, PHONE 1 0.50 12.50 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 20 23.00 1150.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 8 4.75 93.75 19.74
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 3 18.50 925.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 251 1448.50 72325.00 49.93
OCCT-97530-OT SESSION BY LICENSED OT 81 465.25 28640.27 61.56
OCCT-97530HM-OT SESSION BY OT ASST 1 2.00 108.64 54.32
PHY-97110-PT SESSION BY LICENSED PT 53 303.00 19633.02 64.80
SENS-V5264-EARMOLD 1 2.00 37.44 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 278 1694.25 113669.01 67.09
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 572 105915 52957.50 0.50
Subtotal (Total Children Is Unduplicated) 857 109968 294358.08 2.68
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Total 115404.00 498158.61 4.32
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Number of Children (Unduplicated) With at Least One Service 1596
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Center 07
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 2969 103196.75 305906.52 305906.52
D 0 0.00 0.00 0.00
S 5 4.75 288.75 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
8677 12202.50 191963.34 0.00
Other 0 0.00 0.00 0.00
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Total 11651 115404.00 498158.61 305906.52