CMS/EIP Fiscal Report Center: 06
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 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 502 449.50 16631.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1047 3221.50 119195.50 37.00
TCON-TCON-TRANSITION CONFERENCE 197 197.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1500 4815.00 145706.00 30.26
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 17 17.00 150.11 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 17 17.00 183.60 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 17 17.00 370.43 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.00 56.56 28.28
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 18 29.50 2212.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 16 28.00 2100.00 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 7.00 525.00 75.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 5 5.00 286.35 57.27
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 5 5.00 242.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.00 84.90 42.45
SPCH-92506-SPEECH EVAL BY LICENSED SLP 4 4.00 194.00 48.50
Subtotal (Total Children Is Unduplicated) 43 133.50 6405.95 47.98
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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 10 13.75 412.50 30.00
CONOP-CONOP-CONSULT, OT, PHONE 1 1.00 15.00 15.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 7 7.25 240.00 33.10
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 8 11.75 240.00 20.43
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 191 1442.00 66160.00 45.88
INTR-INTR-INTERPRETER 19 76.50 4480.38 58.57
OCCT-97530-OT SESSION BY LICENSED OT 69 293.25 17401.93 59.34
OCCT-97530HM-OT SESSION BY OT ASST 11 36.75 1996.26 54.32
PHY-97110-PT SESSION BY LICENSED PT 115 525.25 31891.49 60.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 414 2439.00 155783.65 63.87
SPL-92508-GROUP SPL SESSION PER CHILD 12 76.75 1013.10 13.20
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) 909 165175 367862.88 2.23
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Total 170123.50 519974.83 3.06
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Number of Children (Unduplicated) With at Least One Service 1665
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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 0 0.00 0.00 0.00
P 13540 165103.00 366234.18 366234.18
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
7148 5020.50 153740.65 888.00
Other 0 0.00 0.00 0.00
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Total 20688 170123.50 519974.83 367122.18