CMS/EIP Fiscal Report Center: 54
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 338 135.25 5004.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 219 228.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 557 738.25 27278.25 36.95
TCM-T1017TL-TARGETED CASE MANAGEMENT 1303 4262.50 156991.00 36.83
Subtotal (Total Children Is Unduplicated) 1313 5364.00 189273.50 35.29
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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 4 4.00 42.48 10.62
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 20 21.00 185.43 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 40 43.00 464.40 10.80
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 6 6.00 50.64 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 36 36.79 801.53 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.00 54.38 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 9 10.00 282.80 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 11 11.00 349.91 31.81
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 1 1.00 125.00 125.00
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 1 1.50 83.25 55.50
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 12 14.50 1087.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 13 15.00 1593.76 106.25
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 23 30.00 2465.63 82.19
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 20 26.00 1443.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 48 60.50 4537.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 82 100.50 7790.63 77.52
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 3.00 225.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 100 136.00 7548.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 119 145.50 12637.54 86.86
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 12 12.00 582.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 26 28.00 1358.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 9 9.00 436.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 21 25.00 1212.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 60 61.00 2958.50 48.50
Subtotal (Total Children Is Unduplicated) 396 803.29 48426.95 60.29
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.00 627.00 627.00
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 14 15.25 762.50 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 59 57.25 2862.50 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 9 4.25 106.25 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 35 33.75 1687.50 50.00
CONOP-CONOP-CONSULT, OT, PHONE 1 0.50 12.50 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 14 8.25 412.50 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 71 79.50 3975.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 7 3.25 81.25 25.00
ECE-ECE-EARLY CHILDHOOD EDUCATION 1 20.00 250.00 12.50
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 11 212.00 10600.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 324 2651.50 133167.25 50.22
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 5 9.50 475.00 50.00
INTR-INTR-INTERPRETER 22 158.00 7900.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 178 1348.02 91183.46 67.64
OCCT-97530HM-OT SESSION BY OT ASST 26 213.50 11597.32 54.32
PHY-97110-PT SESSION BY LICENSED PT 110 682.25 46294.05 67.85
SENS-V5264-EARMOLD 1 2.00 37.44 18.72
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 2 2.00 100.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 290 1862.78 125053.77 67.13
SPL-92508-GROUP SPL SESSION PER CHILD 2 3.50 46.20 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 734 185458 157037.53 0.85
Subtotal (Total Children Is Unduplicated) 869 192826 594269.02 3.08
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Total 198993.34 831969.47 4.18
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Number of Children (Unduplicated) With at Least One Service 1407
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Center 54
Flag Claims Units Chgs Paid
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R 3 1.75 64.75 0.00
U 0 0.00 0.00 0.00
B 1241 1058.25 50598.00 0.00
P 6053 158799.82 433722.87 430631.13
D 77 53.50 1979.50 0.00
S 1 0.50 18.50 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
6602 39078.02 345530.35 0.00
Other 2 1.50 55.50 0.00
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Total 13979 198993.34 831969.47 430631.13