CMS/EIP Fiscal Report Center: 54
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 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 699 2213.25 81575.75 36.86
Subtotal (Total Children Is Unduplicated) 1114 3322.25 114191.25 34.37
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.00 10.62 10.62
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 9 10.00 88.30 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 21 21.91 236.60 10.80
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 2 2.00 16.88 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 18 18.10 394.40 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 6 6.00 169.68 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 6 6.00 190.86 31.81
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 9 11.50 862.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 4.00 300.00 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 7 9.00 675.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 12 16.00 888.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 31 47.00 3525.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 42 45.13 3383.77 74.98
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 9.00 675.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 71 101.00 5605.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 58 71.13 5333.77 74.99
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 6 5.13 248.37 48.42
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 24 23.99 1162.90 48.47
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 4 3.07 148.71 48.44
PSTH-97001-EVAL BY LICENSED PT, INITIAL 4 4.00 194.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 36 35.49 1721.00 48.49
Subtotal (Total Children Is Unduplicated) 231 453.45 26055.86 57.46
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 12 11.00 550.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 76 82.25 4112.50 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 11 5.75 143.75 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 34 30.25 1512.50 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 73 85.00 4250.00 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 159 1281.25 64062.50 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 6 12.00 600.00 50.00
INTR-INTR-INTERPRETER 21 141.75 7087.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 134 730.73 49572.92 67.84
PHY-97110-PT SESSION BY LICENSED PT 56 268.18 18182.75 67.80
PHY-97110HM-PT SESSION BY PT ASST 1 0.04 1.94 48.50
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 1.00 50.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 164 1091.47 74084.39 67.88
TRAN-TRAN-FAMILY TRANSPORTATION 2 210.00 178.50 0.85
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 798 190245 161489.73 0.85
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 4 39.00 1950.00 50.00
Subtotal (Total Children Is Unduplicated) 880 194522 402041.48 2.07
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Total 198297.62 542288.59 2.73
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Number of Children (Unduplicated) With at Least One Service 1312
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Center 54
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 3450 164035.54 366168.64 366168.64
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 0 0.00 0.00 0.00
5389 34086.33 169203.20 0.00
Other 0 0.00 0.00 0.00
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Total 9099 198297.62 542288.59 366168.64