CMS/EIP Fiscal Report Center: 54
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 Page: 1
Payclass Filters:TPIN
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
TCM-T1017TL-TARGETED CASE MANAGEMENT 11 15.00 555.00 37.00
Subtotal (Total Children Is Unduplicated) 11 15.00 555.00 37.00
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Screening, Eval, and Assessment,Class #02
AUD-92626-EVAL OF AUD REHAB STATUS 1 1.00 36.07 36.07
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 2 2.00 21.24 10.62
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 10 10.00 88.30 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 15 15.00 162.00 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 14 14.00 305.06 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.00 54.38 54.38
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 6 6.00 190.86 31.81
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.50 112.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 3.16 706.26 223.50
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 11 16.16 1428.13 88.37
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.00 75.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 12 11.41 856.50 75.07
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 2.00 111.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 20 22.41 2506.52 111.85
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 3 3.00 145.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 6 7.00 339.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 5 4.69 227.94 48.60
PSTH-97001-EVAL BY LICENSED PT, INITIAL 5 5.00 242.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 13 13.00 630.50 48.50
Subtotal (Total Children Is Unduplicated) 78 139.33 8239.76 59.14
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.00 50.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 2 1.25 62.50 50.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 3 1.75 87.50 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 2 2.00 100.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.00 25.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 22 109.00 6042.25 55.43
OCCT-97530-OT SESSION BY LICENSED OT 69 369.17 24994.50 67.70
OCCT-97530HM-OT SESSION BY OT ASST 8 36.75 1996.26 54.32
PHY-97110-PT SESSION BY LICENSED PT 37 177.57 12067.58 67.96
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 76 337.47 22914.98 67.90
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 3 117.00 78.88 0.67
Subtotal (Total Children Is Unduplicated) 155 1153.96 68419.45 59.29
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Total 1308.29 77214.21 59.02
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Number of Children (Unduplicated) With at Least One Service 197
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Center 54
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 32 35.50 4139.16 1681.19
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
635 1272.79 73075.05 0.00
Other 0 0.00 0.00 0.00
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Total 667 1308.29 77214.21 1681.19