CMS/EIP Fiscal Report Center: 52
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 462 245.75 9092.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 423 540.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 382 303.75 11229.50 36.97
TCM-T1017TL-TARGETED CASE MANAGEMENT 820 2436.75 89503.00 36.73
TCON-TCON-TRANSITION CONFERENCE 77 77.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 829 3603.25 109825.25 30.48
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 2 2.00 17.66 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 3 3.00 32.40 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.00 43.58 21.79
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 3 3.00 95.43 31.81
AUDE-92682-CONDITIONED PLAY AUDIOMETRY 1 1.00 21.34 21.34
EXIT-EXIT-TRANSITION ASSESSMENT 5 7.25 362.50 50.00
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 1 1.00 50.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 8 11.00 673.50 61.23
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 2.00 97.00 48.50
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.00 225.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 7.50 416.25 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 49 53.50 2450.00 45.79
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 145 222.00 15136.50 68.18
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 9 14.50 1087.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 45 55.50 3950.50 71.18
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 129 205.50 11405.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 30 46.50 3487.50 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.00 48.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 43 44.00 2134.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 20 20.00 970.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 12 12.00 600.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 56 56.00 2686.88 47.98
VISD-VISD-VISION EVALUATION DIAGNOSTIC 1 1.00 100.00 100.00
VISF-VISF-VISION EVALUATION FUNCTIONAL 3 3.25 162.50 50.00
Subtotal (Total Children Is Unduplicated) 323 777.50 46253.79 59.49
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 4.00 1949.95 487.49
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 58 60.50 3025.00 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 1 0.50 12.50 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 15 10.25 512.50 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 3 1.25 31.25 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 2 1.75 87.50 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 8 3.00 150.00 50.00
CONPP-CONPP-CONSULT, PT, PHONE 2 0.75 18.75 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 9 6.50 325.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 5 2.50 62.50 25.00
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 2 12.50 625.00 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 49 244.00 7340.00 30.08
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 159 834.25 40872.50 48.99
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 3 24.75 1237.50 50.00
INTR-INTR-INTERPRETER 1 1.50 37.50 25.00
OCCT-97530-OT SESSION BY LICENSED OT 109 703.00 47692.52 67.84
OCCT-97530HM-OT SESSION BY OT ASST 1 1.50 81.48 54.32
PHY-97110-PT SESSION BY LICENSED PT 127 669.50 45478.04 67.93
PHY-97110HM-PT SESSION BY PT ASST 2 2.00 108.64 54.32
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 3 6.50 325.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 303 1571.01 106619.14 67.87
SPL-92508-GROUP SPL SESSION PER CHILD 3 18.00 237.60 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 579 124369 60214.50 0.48
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 6 21.25 1062.50 50.00
Subtotal (Total Children Is Unduplicated) 616 128570 318106.87 2.47
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Total 132950.51 474185.91 3.57
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Number of Children (Unduplicated) With at Least One Service 856
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Center 52
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 2502 1775.25 78776.79 0.00
P 548 27793.77 34364.94 34364.94
D 0 0.00 0.00 0.00
S 20 22.00 1168.07 0.00
H 91 167.25 10924.57 0.00
T 0 0.00 0.00 0.00
7450 103192.24 348951.54 0.00
Other 0 0.00 0.00 0.00
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Total 10611 132950.51 474185.91 34364.94