CMS/EIP Fiscal Report Center: 51
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 Page: 1
Eligibility Filter:Part C (excluding not eligible)
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 365 270.50 10008.50 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 299 410.25 15179.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 780 3297.75 121912.75 36.97
Subtotal (Total Children Is Unduplicated) 793 3978.50 147100.50 36.97
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Screening, Eval, and Assessment,Class #02
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
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.00 21.79 21.79
EVAL-EVAL-DEVELOPMENTAL EVALUATION 5 5.00 250.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 5.00 375.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 6 6.00 450.00 75.00
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 8 10.50 580.50 55.29
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 77 87.50 6375.00 72.86
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 16 20.50 1500.00 73.17
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 8.50 637.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 4.50 249.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 109 127.50 9262.50 72.65
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 10 12.00 486.00 40.50
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 6 6.00 291.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 15 15.00 727.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 11 11.00 533.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 14 14.00 679.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 22 22.00 1067.00 48.50
VISF-VISF-VISION EVALUATION FUNCTIONAL 4 7.00 490.00 70.00
Subtotal (Total Children Is Unduplicated) 176 366.00 24070.67 65.77
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 11 24.00 2449.53 102.06
AUD-92630-AUD REHAB PRELING HEARING LOSS 1 2.00 137.72 68.86
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 24 24.25 1137.50 46.91
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 9 97.50 437.50 4.49
CONIP-CONIP-CONSULT, ITDS, PHONE 1 0.50 12.50 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 5 4.75 237.50 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 5 4.50 225.00 50.00
CONPP-CONPP-CONSULT, PT, PHONE 10 3.75 87.50 23.33
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 2 2.25 112.50 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 1 0.50 12.50 25.00
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 4 206.25 10312.50 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 220 1442.25 72062.50 49.97
HERN-EIIF_NM-EI HEARING SERVICES AFTER SHINE NONMED 8 20.50 1025.00 50.00
INTR-INTR-INTERPRETER 5 15.25 383.75 25.16
OCCT-97530-OT SESSION BY LICENSED OT 130 579.25 38226.24 65.99
OCCT-97530HM-OT SESSION BY OT ASST 7 19.00 1052.42 55.39
PHY-97110-PT SESSION BY LICENSED PT 131 723.75 48138.60 66.51
PHY-97110HM-PT SESSION BY PT ASST 27 120.75 6559.14 54.32
SENS-V5264-EARMOLD 2 3.00 56.16 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 220 1449.00 97816.96 67.51
SPL-92508-GROUP SPL SESSION PER CHILD 2 6.00 79.20 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 415 97977.0 47039.00 0.48
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 5 37.75 2227.50 59.01
Subtotal (Total Children Is Unduplicated) 483 102764 329828.72 3.21
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Total 107108.25 500999.89 4.68
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Number of Children (Unduplicated) With at Least One Service 820
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Center 51
Flag Claims Units Chgs Paid
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R 2 1.00 37.00 0.00
U 0 0.00 0.00 0.00
B 3114 2125.75 80685.22 0.00
P 2116 98455.50 162435.00 162425.75
D 13 8.00 303.00 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
4612 6518.00 257539.67 0.00
Other 0 0.00 0.00 0.00
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Total 9857 107108.25 500999.89 162425.75