CMS/EIP Fiscal Report Center: 05
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 274 113.25 4190.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 270 288.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 358 343.00 12691.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 776 2660.75 98447.75 37.00
Subtotal (Total Children Is Unduplicated) 779 3405.00 115329.00 33.87
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.00 8.83 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.00 21.60 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.00 43.58 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 1.36 38.56 28.35
EVAL-EVAL-DEVELOPMENTAL EVALUATION 4 4.00 200.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 21 33.00 1650.00 50.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.00 150.00 75.00
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 29 48.50 2750.25 56.71
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 41 69.01 4849.11 70.27
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 12.50 937.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 18 25.00 1845.75 73.83
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 52 89.00 4939.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 15 25.50 1912.50 75.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 9 9.00 655.02 72.78
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 7 7.00 351.05 50.15
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.00 48.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 5 4.80 232.58 48.45
PSTH-97001-EVAL BY LICENSED PT, INITIAL 3 3.00 145.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 15 16.00 800.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 4 4.00 194.00 48.50
Subtotal (Total Children Is Unduplicated) 164 359.67 21773.83 60.54
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 7.00 929.00 132.71
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 48 41.25 2062.50 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 199 149.50 7475.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 9 4.50 112.50 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 48 42.25 2112.50 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 75 36.25 1812.50 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 133 98.00 4900.00 50.00
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 10 21.00 525.00 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 4 6.00 150.00 25.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 165 881.61 36182.00 41.04
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 215 1210.85 60070.92 49.61
INTR-INTR-INTERPRETER 7 36.50 1825.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 79 258.15 17053.23 66.06
OCCT-97530HM-OT SESSION BY OT ASST 1 4.00 217.28 54.32
PHY-97110-PT SESSION BY LICENSED PT 115 401.22 27108.55 67.57
PHY-97110HM-PT SESSION BY PT ASST 2 1.50 81.48 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 199 772.20 50614.18 65.55
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 4 4.00 217.28 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 4 6.00 79.20 13.20
TRAN-TRAN-FAMILY TRANSPORTATION 1 20.00 459.24 22.96
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 412 94661.0 47330.50 0.50
Subtotal (Total Children Is Unduplicated) 491 98662.8 261317.86 2.65
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Total 102427.45 398420.69 3.89
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Number of Children (Unduplicated) With at Least One Service 814
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Center 05
Flag Claims Units Chgs Paid
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R 1 1.00 72.78 0.00
U 0 0.00 0.00 0.00
B 2378 1291.50 48183.70 0.00
P 3790 97104.09 170963.37 170917.12
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 1 2.25 83.25 0.00
6088 4028.61 179117.59 0.00
Other 0 0.00 0.00 0.00
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Total 12258 102427.45 398420.69 170917.12