CMS/EIP Fiscal Report Center: 09
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 932 836.50 30950.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 738 788.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 799 809.25 29942.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1838 5630.25 208175.00 36.97
TCON-TCON-TRANSITION CONFERENCE 188 287.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1972 8351.00 269067.75 32.22
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Screening, Eval, and Assessment,Class #02
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 2 2.00 32.60 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 2 2.00 17.66 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 3.00 32.40 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.00 43.58 21.79
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.00 46.80 46.80
EVAL-EVAL-DEVELOPMENTAL EVALUATION 4 4.50 225.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 82 132.00 9900.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 11 19.00 1425.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 30 35.00 2581.00 73.74
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 36 65.00 4875.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 23 37.00 2053.50 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 9 9.00 499.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 425 568.00 42486.56 74.80
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 123 183.00 13725.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 277 330.50 24629.06 74.52
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 252 383.50 21284.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 72 85.00 6375.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 3 3.00 145.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 5 5.00 242.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 3 3.00 145.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 6 7.00 310.11 44.30
SCREEN-T1023-INTERDISCIPLINARY SCREENING 13 13.00 650.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 8 9.00 436.50 48.50
Subtotal (Total Children Is Unduplicated) 669 1901.50 132162.02 69.50
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EI Services,Class #03
AUD-HA_FUP-AUDIOLOGY SERVICES 2 3.00 150.00 50.00
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 84 107.00 5350.00 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 1 0.25 6.25 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 23 39.75 1987.50 50.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 60 81.25 4062.50 50.00
CONOP-CONOP-CONSULT, OT, PHONE 1 0.25 6.25 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 16 62.25 3112.50 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 48 87.25 4362.50 50.00
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 1 2.00 100.00 50.00
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 2.00 100.00 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 16 90.00 4500.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 395 3194.25 155652.50 48.73
INTR-INTR-INTERPRETER 13 12.75 637.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 403 2758.75 182278.16 66.07
OCCT-97530HM-OT SESSION BY OT ASST 1 9.50 516.04 54.32
PHY-97110-PT SESSION BY LICENSED PT 325 2014.25 134190.07 66.62
PHY-97110HM-PT SESSION BY PT ASST 10 78.00 4236.96 54.32
SENS-V5264-EARMOLD 5 10.00 187.20 18.72
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 2 2.00 100.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 654 4639.25 311875.64 67.23
SPL-92508-GROUP SPL SESSION PER CHILD 1 0.50 6.60 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 839 183663 91831.50 0.50
Subtotal (Total Children Is Unduplicated) 1241 196857 905249.67 4.60
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Total 207109.75 1306479.44 6.31
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Number of Children (Unduplicated) With at Least One Service 2165
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Center 09
Flag Claims Units Chgs Paid
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R 6 7.75 286.75 0.00
U 0 0.00 0.00 0.00
B 899 833.25 39597.82 204.26
P 12739 125366.75 596464.06 598737.29
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 5135 70674.00 260914.54 260914.54
3659 10228.00 409216.27 2517.10
Other 0 0.00 0.00 0.00
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Total 22438 207109.75 1306479.44 862373.19