CMS/EIP Fiscal Report Center: 09
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 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 816 790.75 29257.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 726 754.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 759 728.25 26945.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1852 5594.75 206894.75 36.98
TCON-TCON-TRANSITION CONFERENCE 172 172.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1960 8039.75 263097.75 32.72
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Screening, Eval, and Assessment,Class #02
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.00 16.30 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.00 8.83 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.00 10.80 10.80
EVAL-EVAL-DEVELOPMENTAL EVALUATION 2 2.00 100.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 73 109.50 8212.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 12 15.00 1125.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 25 31.50 2362.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 33 61.00 4575.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 28 45.00 2497.50 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 3 3.00 166.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 406 534.00 40050.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 94 147.50 11062.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 255 306.50 22987.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 283 431.00 23920.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 79 88.50 6637.50 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 10 10.00 485.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 3 3.00 145.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 6 9.00 426.46 47.38
SCREEN-T1023-INTERDISCIPLINARY SCREENING 4 5.00 250.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 8 8.00 388.00 48.50
Subtotal (Total Children Is Unduplicated) 635 1813.50 125476.39 69.19
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 62 73.75 3687.50 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 23 50.25 2412.50 48.01
CONOF-CONOF-CONSULT, OT, FACE TO FACE 45 50.75 2537.50 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 17 68.00 3400.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 34 45.50 2275.00 50.00
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 1.00 50.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 365 2896.00 140460.00 48.50
INTR-INTR-INTERPRETER 16 53.25 2662.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 365 2546.25 168914.57 66.34
OCCT-97530HM-OT SESSION BY OT ASST 1 0.50 27.16 54.32
PHY-97110-PT SESSION BY LICENSED PT 310 1923.25 128367.15 66.74
PHY-97110HM-PT SESSION BY PT ASST 13 92.50 5024.60 54.32
SENS-V5264-EARMOLD 1 2.00 37.44 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 578 4047.25 272649.50 67.37
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 779 154184 77052.00 0.50
Subtotal (Total Children Is Unduplicated) 1135 166034 809557.42 4.88
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Total 175887.50 1198131.56 6.81
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Number of Children (Unduplicated) With at Least One Service 2093
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Center 09
Flag Claims Units Chgs Paid
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R 35 22.75 841.75 0.00
U 0 0.00 0.00 0.00
B 653 546.25 27351.03 429.50
P 16297 167213.75 774042.68 857551.00
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
4119 8102.75 395822.10 1548.36
Other 6 2.00 74.00 0.00
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Total 21110 175887.50 1198131.56 859528.86