CMS/EIP Fiscal Report Center: 51
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 397 292.00 10804.00 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 356 490.50 18148.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 374 1395.75 51621.00 36.98
Subtotal (Total Children Is Unduplicated) 693 2178.25 80573.50 36.99
----------------------------------------------------------------------------------------------------------------
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
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 44 47.00 3337.50 71.01
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 10 12.50 925.00 74.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 60 66.00 4650.00 70.45
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 6 7.00 283.50 40.50
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.00 48.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 5 5.00 242.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 2 2.00 97.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 3 3.00 145.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 12 12.00 582.00 48.50
VISF-VISF-VISION EVALUATION FUNCTIONAL 3 6.00 420.00 70.00
Subtotal (Total Children Is Unduplicated) 96 184.00 11778.42 64.01
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 9 22.00 2065.42 93.88
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 71 457.25 22812.50 49.89
INTR-INTR-INTERPRETER 5 15.25 383.75 25.16
OCCT-97530-OT SESSION BY LICENSED OT 46 190.75 12194.17 63.93
PHY-97110-PT SESSION BY LICENSED PT 34 174.25 10845.28 62.24
SENS-V5264-EARMOLD 2 3.00 56.16 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 103 718.75 48247.59 67.13
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 446 100834 48385.00 0.48
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 4 28.25 1692.50 59.91
Subtotal (Total Children Is Unduplicated) 480 102790 159395.09 1.55
----------------------------------------------------------------------------------------------------------------
Total 105152.00 251747.01 2.39
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 801
----------------------------------------------------------------------------------------------------------------
Center 51
Flag Claims Units Chgs Paid
-------------------------------------------------
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 2174 101268.00 161173.13 161173.13
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
3748 3870.00 90048.88 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 5942 105152.00 251747.01 161173.13