CMS/EIP Fiscal Report Center: 51
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 Page: 1
Agency Filter:EXT
Eligibility Filter:Part C (excluding not eligible)
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 5 5.00 625.00 125.00
EVAL-EVAL-DEVELOPMENTAL EVALUATION 4 4.00 200.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.50 75.00 50.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.00 75.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 2.50 150.00 60.00
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 2 2.50 138.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 77 83.50 6124.00 73.34
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 7.50 498.50 66.47
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 10 13.00 862.50 66.35
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 12 16.00 874.50 54.66
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 104 117.50 8550.00 72.77
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 14 21.00 1018.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 25 26.00 1261.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 13 15.00 727.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 23 23.00 1115.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 37 38.00 1843.00 48.50
VISF-VISF-VISION EVALUATION FUNCTIONAL 1 2.00 140.00 70.00
Subtotal (Total Children Is Unduplicated) 204 380.00 24353.75 64.09
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 5 19.00 7736.17 407.17
AUD-92630-AUD REHAB PRELING HEARING LOSS 1 2.00 137.72 68.86
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 17 19.25 869.50 45.17
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 4 3.00 150.00 50.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 8 5.75 287.50 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 0.50 25.00 50.00
CONPP-CONPP-CONSULT, PT, PHONE 6 2.00 50.00 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 10 7.75 387.50 50.00
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 10 185.25 9250.00 49.93
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 245 1596.50 79825.00 50.00
HERN-EIIF_NM-EI HEARING SERVICES AFTER SHINE NONMED 10 24.00 1200.00 50.00
INTR-INTR-INTERPRETER 9 25.75 644.50 25.03
OCCT-97530-OT SESSION BY LICENSED OT 141 831.00 55668.86 66.99
OCCT-97530HM-OT SESSION BY OT ASST 12 26.50 1439.48 54.32
PHY-97110-PT SESSION BY LICENSED PT 141 806.00 52971.20 65.72
PHY-97110HM-PT SESSION BY PT ASST 26 155.75 8501.02 54.58
SENS-V5264-EARMOLD 1 2.00 37.44 18.72
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 2 2.00 100.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 227 1394.00 93096.04 66.78
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 2.25 122.22 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 5 9.75 128.70 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 444 101525 48491.10 0.48
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 3 15.50 845.00 54.52
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 1 86.00 4300.00 50.00
Subtotal (Total Children Is Unduplicated) 519 106747 366263.95 3.43
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Total 107126.50 390617.70 3.65
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Number of Children (Unduplicated) With at Least One Service 534
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Center 51
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 2217 103582.50 172220.65 172220.65
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
1457 3544.00 218397.05 0.00
Other 0 0.00 0.00 0.00
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Total 3674 107126.50 390617.70 172220.65