CMS/EIP Fiscal Report Center: 55
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 201 88.75 3283.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 306 411.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 110 83.50 3089.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 645 1929.25 71077.00 36.84
TCON-TCON-TRANSITION CONFERENCE 31 31.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 651 2543.50 77450.25 30.45
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.00 8.83 8.83
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.00 212.00 106.00
EVAL-EVAL-DEVELOPMENTAL EVALUATION 7 13.00 658.25 50.63
EXIT-EXIT-TRANSITION ASSESSMENT 9 14.00 845.75 60.41
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.50 112.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.50 83.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 135 219.50 16462.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 46 79.50 5962.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 39 61.00 4575.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 81 145.50 8047.50 55.31
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 91 137.00 10450.00 76.28
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 7 7.00 339.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 24 24.00 1164.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 4 4.00 194.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 11 11.00 533.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 40 40.00 1940.00 48.50
Subtotal (Total Children Is Unduplicated) 263 761.50 51589.08 67.75
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 6 6.00 1372.85 228.81
AUD-HA_FUP-AUDIOLOGY SERVICES 1 1.00 50.00 50.00
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 4 4.00 200.00 50.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 0.25 12.50 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 2 1.00 50.00 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 19.00 950.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 69 465.75 23287.50 50.00
INTR-INTR-INTERPRETER 2 18.00 792.00 44.00
OCCT-97530-OT SESSION BY LICENSED OT 144 806.25 54707.91 67.85
OCCT-97530HM-OT SESSION BY OT ASST 10 46.50 2525.88 54.32
PHY-97110-PT SESSION BY LICENSED PT 88 477.38 32371.98 67.81
PHY-97110HM-PT SESSION BY PT ASST 17 67.50 3666.60 54.32
SENS-V5050-MED HEARING AID - ANALOG/DIGITAL 1 2.00 474.24 237.12
SENS-V5264-EARMOLD 2 4.00 74.88 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 303 1987.50 126811.96 63.80
SPL-92508-GROUP SPL SESSION PER CHILD 2 2.00 81.08 40.54
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 330 79607.0 59760.10 0.75
Subtotal (Total Children Is Unduplicated) 424 83515.1 307189.48 3.68
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Total 86820.13 436228.81 5.02
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Number of Children (Unduplicated) With at Least One Service 775
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Center 55
Flag Claims Units Chgs Paid
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R 5 4.75 175.75 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 4129 47264.36 137960.45 137960.45
D 56 56.00 2585.00 0.00
S 2 2.25 83.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
8006 39492.77 295424.36 0.00
Other 0 0.00 0.00 0.00
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Total 12198 86820.13 436228.81 137960.45