CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2009 ending 09/30/2009 Date of Report:11/17/2009 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 213 98.50 3644.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 350 410.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 444 399.50 14781.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 713 2051.75 75914.75 37.00
TCON-TCON-TRANSITION CONFERENCE 55 55.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 720 3014.75 94340.75 31.29
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 13 14.00 679.00 48.50
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 5 5.00 44.15 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 6 6.00 64.80 10.80
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.00 8.44 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 7 7.00 152.53 21.79
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.00 31.81 31.81
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 4 4.00 400.00 100.00
EXIT-EXIT-TRANSITION ASSESSMENT 55 102.25 5112.50 50.00
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 2 3.50 194.25 55.50
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.00 300.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 2.50 187.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.00 312.72 78.18
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 9 13.00 721.50 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 100 190.50 10572.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 71 137.50 10313.10 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 50 94.00 7050.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 156 297.50 16511.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 65 118.50 8887.50 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 20 24.00 1164.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 22 24.00 1164.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 1.00 50.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 29 36.00 1746.00 48.50
Subtotal (Total Children Is Unduplicated) 286 1090.25 65667.80 60.23
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 8.00 673.60 84.20
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 113 145.00 7250.00 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 41 33.00 825.00 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 8 25.00 1250.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 1 1.00 25.00 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 4 7.50 375.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 1 0.25 6.25 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 13 26.75 1337.50 50.00
CONPP-CONPP-CONSULT, PT, PHONE 2 1.50 37.50 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 12 52.50 2625.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 6 34.75 868.75 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 14 22.00 550.00 25.00
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 21 123.00 6150.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 436 2634.50 131725.00 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 7 12.00 600.00 50.00
INTR-INTR-INTERPRETER 12 26.00 1300.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 46 279.50 18972.46 67.88
OCCT-97530HM-OT SESSION BY OT ASST 1 0.50 27.16 54.32
PHY-97110-PT SESSION BY LICENSED PT 41 261.25 17733.65 67.88
PHY-97110HM-PT SESSION BY PT ASST 1 1.00 54.32 54.32
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 11 20.00 1000.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 73 533.19 36193.16 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 1 3.00 39.60 13.20
TRAN-TRAN-FAMILY TRANSPORTATION 1 45.00 4500.00 100.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 590 98293.0 49146.50 0.50
Subtotal (Total Children Is Unduplicated) 627 102589 283265.45 2.76
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Total 106694.19 443274.00 4.15
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Number of Children (Unduplicated) With at Least One Service 838
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Center 53
Flag Claims Units Chgs Paid
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R 18 19.75 1016.50 0.00
U 0 0.00 0.00 0.00
B 805 732.00 28642.00 0.00
P 1792 19164.96 90104.62 90128.18
D 11 16.00 894.50 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 1862 34015.43 61709.18 61709.18
6718 52746.05 260907.20 800.00
Other 0 0.00 0.00 0.00
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Total 11206 106694.19 443274.00 152637.36