CMS/EIP Fiscal Report Center: 06
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 459 267.00 9879.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 651 680.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 503 451.00 16687.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1816 5855.00 216635.00 37.00
TCON-TCON-TRANSITION CONFERENCE 197 197.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1825 7450.00 243201.00 32.64
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 130 130.00 1147.90 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 130 130.00 1404.00 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 126 126.00 2745.54 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 9 9.00 254.52 28.28
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 12 18.50 1387.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 12 19.00 1425.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.50 112.50 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 315 468.50 35137.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 292 430.50 32287.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.00 111.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 40 68.00 5100.00 75.00
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 5 5.00 136.10 27.22
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 26 26.00 1489.02 57.27
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 7 7.00 339.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 5 5.00 374.42 74.88
SPCH-92506-SPEECH EVAL BY LICENSED SLP 15 15.00 727.50 48.50
Subtotal (Total Children Is Unduplicated) 432 1461.00 84179.50 57.62
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 5 5.00 1039.57 207.91
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 21 23.50 660.00 28.09
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 3 1.75 26.00 14.86
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 1.00 30.00 30.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 19 27.25 1087.50 39.91
CONOP-CONOP-CONSULT, OT, PHONE 1 1.00 15.00 15.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 11 15.25 640.00 41.97
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 14 25.75 940.00 36.50
CONSP-CONSP-CONSULT, SLP, PHONE 2 1.50 37.50 25.00
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 9 112.00 5600.00 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 15.00 750.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 304 2217.50 104935.00 47.32
INTR-INTR-INTERPRETER 19 76.50 4480.38 58.57
OCCT-97530-OT SESSION BY LICENSED OT 179 935.25 63619.09 68.02
OCCT-97530HM-OT SESSION BY OT ASST 20 56.75 3082.66 54.32
PHY-97110-PT SESSION BY LICENSED PT 232 1250.25 82589.62 66.06
PHY-97110HM-PT SESSION BY PT ASST 13 28.00 1717.93 61.35
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 618 3634.00 240085.33 66.07
SPL-92508-GROUP SPL SESSION PER CHILD 35 116.25 1782.27 15.33
TRAN-TRAN-FAMILY TRANSPORTATION 3 122.00 104.50 0.86
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 730 159970 79981.00 0.50
Subtotal (Total Children Is Unduplicated) 1005 168636 593203.35 3.52
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Total 177546.50 920583.85 5.19
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Number of Children (Unduplicated) With at Least One Service 1909
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Center 06
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 1633 1196.00 44252.00 619.75
P 15080 166293.25 418709.43 418671.93
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
13517 10057.25 457622.42 888.00
Other 0 0.00 0.00 0.00
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Total 30230 177546.50 920583.85 420179.68