CMS/EIP Fiscal Report Center: 54
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 Page: 1
Eligibility Filter:Part C (excluding not eligible)
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 293 120.50 4458.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 213 221.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 447 583.25 21571.00 36.98
TCM-T1017TL-TARGETED CASE MANAGEMENT 1235 3836.75 141552.75 36.89
Subtotal (Total Children Is Unduplicated) 1253 4761.50 167582.25 35.20
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 4 4.00 42.48 10.62
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 34 35.00 309.05 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 47 50.00 540.00 10.80
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 3 4.00 33.76 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 47 49.00 1067.71 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 3 3.00 163.14 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 8 8.00 226.24 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 21 22.00 699.82 31.81
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 1 1.00 125.00 125.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 12 17.00 1275.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 7 8.00 600.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 3.00 225.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 20 24.00 2053.13 85.55
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 15 19.00 1054.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 46 67.50 5062.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 44 53.50 4012.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 10.00 750.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 69 199.00 11044.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 83 104.50 9243.78 88.46
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 13 14.00 679.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 28 29.00 1406.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 12 12.00 582.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 22 22.00 1067.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 61 63.00 3055.50 48.50
Subtotal (Total Children Is Unduplicated) 333 821.50 45318.11 55.17
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 14 12.00 600.00 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 1 1.00 25.00 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 76 82.75 4137.50 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 11 5.75 143.75 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 35 32.00 1600.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 2 1.75 43.75 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 11 6.25 312.50 50.00
CONPP-CONPP-CONSULT, PT, PHONE 1 0.75 18.75 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 74 87.50 4375.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 6 3.50 87.50 25.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 22 274.75 13737.50 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 345 2597.00 130202.46 50.14
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 7 13.00 650.00 50.00
INTR-INTR-INTERPRETER 21 141.75 7087.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 185 1174.25 79707.57 67.88
OCCT-97530HM-OT SESSION BY OT ASST 35 310.00 16839.20 54.32
PHY-97110-PT SESSION BY LICENSED PT 121 706.00 47935.44 67.90
PHY-97110HM-PT SESSION BY PT ASST 1 0.50 33.94 67.88
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 1.00 50.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 301 1939.75 132230.24 68.17
TRAN-TRAN-FAMILY TRANSPORTATION 2 210.00 178.50 0.85
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 708 185572 157522.93 0.85
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 4 39.00 1950.00 50.00
Subtotal (Total Children Is Unduplicated) 842 193212 599469.03 3.10
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Total 198795.25 812369.39 4.09
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Number of Children (Unduplicated) With at Least One Service 1321
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Center 54
Flag Claims Units Chgs Paid
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R 5 2.75 101.75 0.00
U 0 0.00 0.00 0.00
B 94 89.00 4788.26 0.00
P 6850 163019.29 459028.23 457413.41
D 254 172.00 6778.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 1 0.25 9.25 0.00
6101 35511.96 341663.90 0.00
Other 0 0.00 0.00 0.00
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Total 13305 198795.25 812369.39 457413.41