CMS/EIP Fiscal Report Center: 09
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 813 786.50 29100.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 726 754.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 758 726.75 26889.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1032 3219.00 118992.00 36.97
TCON-TCON-TRANSITION CONFERENCE 171 171.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1707 5657.25 174982.25 30.93
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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 43 67.50 5062.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 6 7.50 562.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 9 12.00 900.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 18 35.00 2625.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 16 26.00 1443.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 200 266.50 19987.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 50 77.50 5812.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 120 141.00 10575.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 125 189.50 10517.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 59 67.50 5062.50 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 2 2.00 97.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.00 86.96 43.48
SCREEN-T1023-INTERDISCIPLINARY SCREENING 3 3.00 150.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 2 2.00 97.00 48.50
Subtotal (Total Children Is Unduplicated) 344 904.00 63114.64 69.82
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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 50.50 2525.00 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 222 1767.75 84047.50 47.54
INTR-INTR-INTERPRETER 16 53.25 2662.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 188 1288.00 83504.56 64.83
PHY-97110-PT SESSION BY LICENSED PT 131 690.25 44671.11 64.72
PHY-97110HM-PT SESSION BY PT ASST 1 6.00 325.92 54.32
SENS-V5264-EARMOLD 1 2.00 37.44 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 397 2750.75 184643.08 67.12
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 779 154184 77052.00 0.50
Subtotal (Total Children Is Unduplicated) 981 161031 491294.11 3.05
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Total 167592.25 729391.00 4.35
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Number of Children (Unduplicated) With at Least One Service 1868
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Center 09
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 13537 164797.25 662752.56 663178.06
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
979 2795.00 66638.44 1548.36
Other 0 0.00 0.00 0.00
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Total 14516 167592.25 729391.00 664726.42