CMS/EIP Fiscal Report Center: 55
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 201 88.75 3283.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 305 410.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 110 83.50 3089.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 305 882.75 32495.25 36.81
TCON-TCON-TRANSITION CONFERENCE 31 31.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 529 1496.00 38868.50 25.98
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.00 212.00 106.00
EVAL-EVAL-DEVELOPMENTAL EVALUATION 5 7.50 383.25 51.10
EXIT-EXIT-TRANSITION ASSESSMENT 6 8.00 470.75 58.84
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 74 112.54 8440.31 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 16 24.47 1835.32 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 12 18.50 1387.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 38 67.00 3718.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 33 49.50 3712.50 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 4 3.79 184.00 48.55
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 7 7.00 339.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 19 18.59 901.50 48.49
Subtotal (Total Children Is Unduplicated) 162 322.89 21829.38 67.61
----------------------------------------------------------------------------------------------------------------
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 26 181.50 9075.00 50.00
INTR-INTR-INTERPRETER 2 18.00 792.00 44.00
OCCT-97530-OT SESSION BY LICENSED OT 55 225.87 15327.12 67.86
PHY-97110-PT SESSION BY LICENSED PT 40 187.68 12741.50 67.89
PHY-97110HM-PT SESSION BY PT ASST 4 12.00 651.84 54.32
SENS-V5050-MED HEARING AID - ANALOG/DIGITAL 1 2.00 474.24 237.12
SENS-V5264-EARMOLD 1 2.00 37.44 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 131 894.90 52678.29 58.87
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 330 79607.0 59760.10 0.75
Subtotal (Total Children Is Unduplicated) 365 81162.2 154172.88 1.90
----------------------------------------------------------------------------------------------------------------
Total 82981.09 214870.76 2.59
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 664
----------------------------------------------------------------------------------------------------------------
Center 55
Flag Claims Units Chgs Paid
-------------------------------------------------
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 3036 46175.11 94406.39 94406.39
D 55 55.00 2548.00 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
4263 36750.98 117916.37 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 7354 82981.09 214870.76 94406.39