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: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 397 292.00 10804.00 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 356 490.50 18148.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 856 3658.50 135260.50 36.97
Subtotal (Total Children Is Unduplicated) 869 4441.00 164213.00 36.98
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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 7 7.00 350.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 8.00 600.00 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 8 9.00 675.00 75.00
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 9 12.50 655.50 52.44
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 105 120.50 8850.00 73.44
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 20 25.00 1825.00 73.00
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 142 167.00 12225.00 73.20
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 11 13.00 526.50 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 15 15.00 727.50 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) 214 455.00 30547.17 67.14
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 12 28.00 2849.90 101.78
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 222 1453.25 72612.50 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 132 730.00 48562.85 66.52
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 224 1482.00 100057.00 67.51
SPL-92508-GROUP SPL SESSION PER CHILD 2 6.00 79.20 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 446 100834 48385.00 0.48
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 5 37.75 2227.50 59.01
Subtotal (Total Children Is Unduplicated) 514 105675 334789.38 3.17
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Total 110571.00 529549.55 4.79
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Number of Children (Unduplicated) With at Least One Service 896
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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 3387 2353.25 89820.72 0.00
P 2217 101382.75 168446.87 168437.62
D 20 14.00 525.00 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
5005 6820.00 270719.96 0.00
Other 0 0.00 0.00 0.00
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Total 10631 110571.00 529549.55 168437.62