CMS/EIP Fiscal Report Center: 52
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 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 431 1200.50 44076.25 36.71
TCON-TCON-TRANSITION CONFERENCE 77 77.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 767 2367.00 64398.50 27.21
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Screening, Eval, and Assessment,Class #02
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-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.00 31.81 31.81
EXIT-EXIT-TRANSITION ASSESSMENT 4 4.75 237.50 50.00
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 1 1.00 50.00 50.00
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 45 47.50 2250.00 47.37
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 6.00 423.50 70.58
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 1.24 60.00 48.39
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 21 31.50 1748.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.00 225.00 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 5 5.00 242.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 1.00 50.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 11 11.00 518.94 47.18
Subtotal (Total Children Is Unduplicated) 90 115.99 5918.59 51.03
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EI Services,Class #03
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 14 9.25 462.50 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 6.25 312.50 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 5 2.50 62.50 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 40 211.91 10595.32 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 1 7.00 350.00 50.00
INTR-INTR-INTERPRETER 1 1.50 37.50 25.00
OCCT-97530-OT SESSION BY LICENSED OT 26 130.70 8869.48 67.86
PHY-97110-PT SESSION BY LICENSED PT 29 164.75 11183.23 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 94 500.62 33980.45 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 579 118812 59406.00 0.50
Subtotal (Total Children Is Unduplicated) 596 119914 128584.48 1.07
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Total 122397.22 198901.57 1.63
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Number of Children (Unduplicated) With at Least One Service 832
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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 0 0.00 0.00 0.00
P 548 27793.77 34364.94 34364.94
D 0 0.00 0.00 0.00
S 1 1.50 101.82 0.00
H 1 1.50 83.25 0.00
T 0 0.00 0.00 0.00
5925 94600.45 164351.56 0.00
Other 0 0.00 0.00 0.00
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Total 6475 122397.22 198901.57 34364.94