CMS/EIP Fiscal Report Center: 55
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 204 96.00 3533.50 36.81
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 316 406.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 124 83.00 3052.50 36.78
TCM-T1017TL-TARGETED CASE MANAGEMENT 625 1979.00 72732.75 36.75
TCON-TCON-TRANSITION CONFERENCE 34 34.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 629 2598.00 79318.75 30.53
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Screening, Eval, and Assessment,Class #02
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.00 46.80 46.80
EVAL-EVAL-DEVELOPMENTAL EVALUATION 8 19.50 1225.00 62.82
EXIT-EXIT-TRANSITION ASSESSMENT 13 26.50 1800.00 67.92
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.00 300.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.50 262.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.50 112.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.00 111.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 105 183.00 13725.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 55 95.00 7087.50 74.61
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 27 40.00 3000.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 57 105.50 5688.75 53.92
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 70 104.50 7837.50 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 5 5.00 242.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 22 24.66 1196.20 48.51
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 2 2.00 97.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 14 14.00 679.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 27 27.00 1309.50 48.50
Subtotal (Total Children Is Unduplicated) 224 658.66 44720.75 67.90
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 7 7.75 387.50 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 2.00 100.00 50.00
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 4.00 200.00 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 5 31.00 1550.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 69 387.00 19350.00 50.00
INTR-INTR-INTERPRETER 3 26.50 1165.50 43.98
OCCT-97530-OT SESSION BY LICENSED OT 141 668.34 45293.50 67.77
OCCT-97530HM-OT SESSION BY OT ASST 12 67.00 3639.44 54.32
PHY-97110-PT SESSION BY LICENSED PT 92 460.35 31228.07 67.84
PHY-97110HM-PT SESSION BY PT ASST 16 37.75 2050.58 54.32
SENS-V5264-EARMOLD 2 4.00 74.88 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 264 1517.75 103024.87 67.88
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 3.00 162.96 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.00 13.20 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 277 61761.0 46420.14 0.75
Subtotal (Total Children Is Unduplicated) 379 64978.4 254660.64 3.92
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Total 68235.10 378700.14 5.55
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Number of Children (Unduplicated) With at Least One Service 725
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Center 55
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 9 9.25 399.25 0.00
P 3793 35756.84 127830.48 127867.98
D 47 52.50 2056.50 0.00
S 17 18.25 713.75 0.00
H 0 0.00 0.00 0.00
T 2078 28680.57 66000.88 66000.88
4647 3717.69 181699.28 0.00
Other 0 0.00 0.00 0.00
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Total 10591 68235.10 378700.14 193868.86