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: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 323 130.50 4828.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 219 227.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 563 751.50 27787.00 36.98
TCM-T1017TL-TARGETED CASE MANAGEMENT 1407 4518.75 166740.50 36.90
Subtotal (Total Children Is Unduplicated) 1425 5627.75 199356.00 35.42
----------------------------------------------------------------------------------------------------------------
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 9 11.00 825.00 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 24 29.50 2465.63 83.58
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 16 20.50 1137.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 62 89.00 6675.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 73 89.00 6675.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 12.00 900.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 117 255.50 14180.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 144 173.00 15103.17 87.30
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 23 23.00 1115.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 61 63.00 3055.50 48.50
Subtotal (Total Children Is Unduplicated) 433 1016.50 59507.50 58.54
----------------------------------------------------------------------------------------------------------------
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 12 6.25 156.25 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 12 6.50 325.00 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 346 2598.00 130252.46 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 302 1942.00 132382.97 68.17
TRAN-TRAN-FAMILY TRANSPORTATION 2 210.00 178.50 0.85
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 799 190410 161629.98 0.85
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 4 39.00 1950.00 50.00
Subtotal (Total Children Is Unduplicated) 934 198054 603803.81 3.05
----------------------------------------------------------------------------------------------------------------
Total 204698.50 862667.31 4.21
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1496
----------------------------------------------------------------------------------------------------------------
Center 54
Flag Claims Units Chgs Paid
-------------------------------------------------
R 6 3.25 120.25 0.00
U 0 0.00 0.00 0.00
B 100 96.75 5360.01 0.00
P 7439 166817.54 480586.15 478518.03
D 260 175.75 6916.75 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
6871 37603.46 369591.65 0.00
Other 1 1.50 83.25 0.00
-------------------------------------------------
Total 14678 204698.50 862667.31 478518.03