CMS/EIP Fiscal Report Center: 51
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 429 336.25 12441.25 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 330 461.50 17075.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 371 1438.25 53196.75 36.99
Subtotal (Total Children Is Unduplicated) 713 2236.00 82713.50 36.99
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.00 8.83 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.00 10.80 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.00 21.79 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.00 28.28 28.28
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 4 4.00 500.00 125.00
EVAL-EVAL-DEVELOPMENTAL EVALUATION 5 5.00 250.00 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 1 1.50 75.00 50.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 51 52.50 3836.50 73.08
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 10 10.50 723.50 68.90
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 4.50 225.00 50.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 5 7.00 375.00 53.57
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 60 63.50 4500.00 70.87
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 4 4.00 162.00 40.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 14 15.00 727.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 8 8.00 388.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 25 27.00 1309.50 48.50
VISF-VISF-VISION EVALUATION FUNCTIONAL 1 2.00 140.00 70.00
Subtotal (Total Children Is Unduplicated) 115 212.00 13506.70 63.71
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 5 14.00 4321.17 308.66
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 12 9.50 475.00 50.00
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 9 180.50 9012.50 49.93
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 80 501.50 25075.00 50.00
INTR-INTR-INTERPRETER 9 25.75 644.50 25.03
OCCT-97530-OT SESSION BY LICENSED OT 42 254.25 16519.07 64.97
OCCT-97530HM-OT SESSION BY OT ASST 1 1.00 54.32 54.32
PHY-97110-PT SESSION BY LICENSED PT 29 164.50 9582.82 58.25
PHY-97110HM-PT SESSION BY PT ASST 2 6.00 325.92 54.32
SENS-V5264-EARMOLD 1 2.00 37.44 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 111 710.25 46866.93 65.99
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 478 103857 49597.10 0.48
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 3 7.50 445.00 59.33
Subtotal (Total Children Is Unduplicated) 501 105766 164476.49 1.56
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Total 108214.25 260696.69 2.41
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Number of Children (Unduplicated) With at Least One Service 830
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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 2256 104670.75 170237.60 170237.60
D 13 10.75 442.75 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
3826 3532.75 90016.34 0.00
Other 0 0.00 0.00 0.00
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Total 6095 108214.25 260696.69 170237.60