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: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 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 627 1897.25 69772.75 36.78
Subtotal (Total Children Is Unduplicated) 1045 2998.75 102055.25 34.03
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.00 10.62 10.62
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 5 5.00 44.15 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 17 18.00 194.40 10.80
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 6 6.00 50.64 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 16 15.79 343.94 21.78
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 9 10.00 282.80 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.00 31.81 31.81
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 8 10.50 787.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 2.84 212.50 74.82
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 5 4.84 362.50 74.90
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 12 16.00 888.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 33 45.00 3375.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 27 28.59 2143.50 74.97
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 50 73.00 4051.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 37 44.59 3343.50 74.98
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 3 3.00 145.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 9 9.00 436.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 2 1.31 63.06 48.14
PSTH-97001-EVAL BY LICENSED PT, INITIAL 8 8.00 388.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 25 26.00 1261.00 48.50
Subtotal (Total Children Is Unduplicated) 180 334.96 18799.67 56.13
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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 13 14.25 712.50 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 58 56.00 2800.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 9 4.25 106.25 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 34 32.00 1600.00 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 70 77.50 3875.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 6 2.25 56.25 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 146 1416.75 70837.50 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 3 6.50 325.00 50.00
INTR-INTR-INTERPRETER 22 158.00 7900.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 117 693.85 47043.25 67.80
PHY-97110-PT SESSION BY LICENSED PT 57 267.43 18121.94 67.76
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 159 1061.56 70710.35 66.61
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 733 185341 156958.65 0.85
Subtotal (Total Children Is Unduplicated) 817 189377 393086.13 2.08
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Total 192710.80 513941.05 2.67
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Number of Children (Unduplicated) With at Least One Service 1257
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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 3141 156859.32 357573.31 357647.31
D 77 53.50 1979.50 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
5174 35797.98 154388.24 0.00
Other 0 0.00 0.00 0.00
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Total 8392 192710.80 513941.05 357647.31