CMS/EIP Fiscal Report Center: 01
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 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 851 415.50 15373.50 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 860 955.25 35344.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1222 3147.00 116402.00 36.99
Subtotal (Total Children Is Unduplicated) 1879 4517.75 167119.75 36.99
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 7 8.00 270.50 33.81
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 6 6.00 52.98 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 8 8.00 86.40 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 7 7.00 132.27 18.90
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.00 56.56 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 2 2.00 63.62 31.81
AUDE-92682-CONDITIONED PLAY AUDIOMETRY 1 1.00 21.34 21.34
EVAL-EVAL-DEVELOPMENTAL EVALUATION 3 4.75 237.50 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 82 164.75 8237.50 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 9 14.00 1050.00 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 11 17.50 971.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 151 223.00 16725.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 24 37.50 2749.00 73.31
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 15 23.00 1725.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 123 192.50 10635.25 55.25
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 41 56.50 4237.50 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 6 6.00 253.94 42.32
SPCH-92506-SPEECH EVAL BY LICENSED SLP 14 14.00 612.50 43.75
Subtotal (Total Children Is Unduplicated) 347 789.00 48230.61 61.13
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 7 47.00 9448.19 201.03
AUD-HA_FUP-AUDIOLOGY SERVICES 2 2.00 100.00 50.00
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 54 74.75 3737.50 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 9 2.25 56.25 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 17 13.00 650.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 4 2.75 68.75 25.00
CONOP-CONOP-CONSULT, OT, PHONE 1 0.25 6.25 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 13 10.00 500.00 50.00
CONPP-CONPP-CONSULT, PT, PHONE 3 2.50 62.50 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 15 10.00 500.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 15 9.25 231.25 25.00
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 10 24.00 720.00 30.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 40 204.00 6025.00 29.53
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 12 49.75 2487.50 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 12 52.00 2600.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 234 1345.25 67262.50 50.00
INTR-INTR-INTERPRETER 75 442.00 15110.00 34.19
OCCT-97530-OT SESSION BY LICENSED OT 69 400.00 26446.37 66.12
OCCT-97530HM-OT SESSION BY OT ASST 1 3.00 162.96 54.32
PHY-97110-PT SESSION BY LICENSED PT 98 546.75 36398.52 66.57
PHY-97110HM-PT SESSION BY PT ASST 5 17.00 913.91 53.76
RSPT-RSPT-RESPITE 1 97.50 756.00 7.75
SENS-V5264-EARMOLD 1 2.00 37.44 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 506 3030.50 203189.18 67.05
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 1.00 54.32 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 19 59.75 890.17 14.90
TRAN-TRAN-FAMILY TRANSPORTATION 1 60.00 6000.00 100.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1150 238895 119436.20 0.50
Subtotal (Total Children Is Unduplicated) 1298 245403 503850.76 2.05
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Total 250710.00 719201.12 2.87
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Number of Children (Unduplicated) With at Least One Service 2240
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Center 01
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 7043 143957.50 279905.75 279905.75
D 2 1.50 34.44 0.00
S 495 3516.25 16492.25 0.00
H 2 3.00 150.00 0.00
T 5727 94173.25 241092.13 241092.13
7201 5180.75 164954.27 0.00
Other 303 3877.75 16572.28 0.00
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Total 20773 250710.00 719201.12 520997.88