CMS/EIP Fiscal Report Center: 03
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 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 752 442.75 16381.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 587 828.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 266 285.25 10554.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1244 3583.00 132571.00 37.00
TCON-TCON-TRANSITION CONFERENCE 164 164.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1275 5303.00 159507.00 30.08
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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-92553-PURE TONE AUDIOMETRY AIR & BONE 5 5.00 81.50 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 79 79.00 697.57 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 30 30.00 324.00 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 77 77.00 1677.83 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 4 4.00 217.52 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 8 8.00 226.24 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.00 31.81 31.81
EXIT-EXIT-TRANSITION ASSESSMENT 25 40.00 2000.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 8 13.00 975.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 11 21.50 1193.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 143 244.00 18262.50 74.85
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 52 109.50 6852.50 62.58
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 228 402.00 22311.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 4.00 300.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 10 10.00 358.00 35.80
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 18 18.00 793.00 44.06
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 4 5.00 172.50 34.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 17 17.00 726.94 42.76
SCREEN-T1023-INTERDISCIPLINARY SCREENING 232 232.00 11600.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 23 24.00 1070.19 44.59
Subtotal (Total Children Is Unduplicated) 521 1345.00 69881.97 51.96
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 3 8.00 3816.12 477.02
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 145 182.25 8965.00 49.19
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 9 9.50 237.50 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 52 87.25 4362.50 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 7 6.50 162.50 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 18 42.25 2075.00 49.11
CONOP-CONOP-CONSULT, OT, PHONE 1 1.00 25.00 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 20 41.50 2075.00 50.00
CONPP-CONPP-CONSULT, PT, PHONE 1 1.00 6.25 6.25
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 47 85.50 4275.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.00 6.25 6.25
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 162 1200.00 59550.00 49.63
INTR-INTR-INTERPRETER 12 82.50 4489.75 54.42
OCCT-97530-OT SESSION BY LICENSED OT 77 335.00 18223.69 54.40
PHY-97110-PT SESSION BY LICENSED PT 65 372.50 20666.68 55.48
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 2 6.00 300.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 168 901.25 53760.51 59.65
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 417 76098.0 37980.80 0.50
Subtotal (Total Children Is Unduplicated) 570 79461.0 220977.55 2.78
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Total 86109.00 450366.52 5.23
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Number of Children (Unduplicated) With at Least One Service 1332
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Center 03
Flag Claims Units Chgs Paid
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R 3 0.75 27.75 0.00
U 0 0.00 0.00 0.00
B 77 47.00 1792.75 0.00
P 6708 58124.00 227359.19 234493.69
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 5030 18728.00 132174.17 132174.17
3042 9009.25 85721.83 0.00
Other 199 200.00 3290.83 27.75
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Total 15059 86109.00 450366.52 366695.61