CMS/EIP Fiscal Report Center: 09
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 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 799 808.25 29905.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 991 3105.75 114894.25 36.99
TCON-TCON-TRANSITION CONFERENCE 187 286.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1749 5824.50 175750.00 30.17
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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) 1 1.00 8.83 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 2.00 21.60 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 19 35.50 2662.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 5.00 375.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 3.00 181.00 60.33
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 10 18.00 1350.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 9 16.00 888.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 113 166.50 12374.06 74.32
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 37 62.50 4687.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 61 77.50 5654.06 72.96
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 78 134.50 7464.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 11 12.00 900.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.00 48.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.00 67.61 33.81
SCREEN-T1023-INTERDISCIPLINARY SCREENING 7 7.00 350.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 3 3.00 145.50 48.50
Subtotal (Total Children Is Unduplicated) 190 557.00 37575.39 67.46
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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-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 227 1861.00 89130.00 47.89
INTR-INTR-INTERPRETER 13 12.75 637.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 193 1303.00 83461.85 64.05
OCCT-97530HM-OT SESSION BY OT ASST 1 9.50 516.04 54.32
PHY-97110-PT SESSION BY LICENSED PT 127 708.50 45661.02 64.45
PHY-97110HM-PT SESSION BY PT ASST 1 5.00 271.60 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 407 2939.75 196513.58 66.85
SPL-92508-GROUP SPL SESSION PER CHILD 1 0.50 6.60 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 839 183638 91819.00 0.50
Subtotal (Total Children Is Unduplicated) 1052 190875 527541.89 2.76
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Total 197256.50 740867.28 3.76
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Number of Children (Unduplicated) With at Least One Service 1945
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Center 09
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 9463 122378.25 456488.97 456621.17
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
391 4204.25 23463.77 1979.59
Other 0 0.00 0.00 0.00
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Total 14989 197256.50 740867.28 719515.30