CMS/EIP Fiscal Report Center: 05
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 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 366 1274.25 47147.25 37.00
Subtotal (Total Children Is Unduplicated) 639 2018.50 64028.50 31.72
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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
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 22 38.50 2166.00 56.26
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 28 37.10 2569.22 69.25
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 4.26 319.32 74.96
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 2.77 178.60 64.48
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 26 37.00 2053.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 11 19.50 1462.50 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 0.80 38.58 48.23
Subtotal (Total Children Is Unduplicated) 96 181.29 10700.29 59.02
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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 47 40.25 2012.50 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 198 149.00 7450.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 9 4.50 112.50 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 48 41.25 2062.50 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 131 601.61 22182.00 36.87
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 119 663.85 32720.92 49.29
INTR-INTR-INTERPRETER 7 36.50 1825.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 10 24.93 1314.01 52.71
PHY-97110-PT SESSION BY LICENSED PT 11 30.97 1975.98 63.80
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 68 295.94 18680.40 63.12
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 0.50 27.16 54.32
TRAN-TRAN-FAMILY TRANSPORTATION 1 20.00 459.24 22.96
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 412 93700.0 46850.00 0.50
Subtotal (Total Children Is Unduplicated) 466 95777.6 145988.71 1.52
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Total 97977.34 220717.50 2.25
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Number of Children (Unduplicated) With at Least One Service 740
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Center 05
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 3570 95873.09 155291.12 155291.12
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 0 0.00 0.00 0.00
3463 2104.25 65426.38 0.00
Other 0 0.00 0.00 0.00
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Total 7033 97977.34 220717.50 155291.12