CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2009 ending 09/30/2009 Date of Report:11/17/2009 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 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 242 637.75 23596.75 37.00
TCON-TCON-TRANSITION CONFERENCE 55 55.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 604 1600.75 42022.75 26.25
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 13 12.91 626.01 48.49
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 3 3.00 26.49 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 4 4.00 43.20 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 5 5.00 108.95 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 1 1.50 83.25 55.50
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.00 150.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 0.17 12.72 74.82
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.00 166.50 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 93 173.78 9644.31 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 19 34.57 2593.06 75.01
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 17 31.44 2358.33 75.01
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 50 88.61 4917.58 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 22 39.04 2927.71 74.99
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 3.00 145.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 5 5.00 242.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 10 10.00 485.00 48.50
Subtotal (Total Children Is Unduplicated) 195 525.27 30150.42 57.40
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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
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 5 33.75 843.75 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 4 7.00 175.00 25.00
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 21 123.00 6150.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 106 590.00 29500.00 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 2 4.00 200.00 50.00
INTR-INTR-INTERPRETER 12 26.00 1300.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 15 104.75 7109.50 67.87
PHY-97110-PT SESSION BY LICENSED PT 11 50.25 3410.97 67.88
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 4 7.00 350.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 38 291.27 19773.19 67.89
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) 615 99875.3 136857.51 1.37
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Total 102001.29 209030.68 2.05
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Number of Children (Unduplicated) With at Least One Service 787
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Center 53
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 624 17925.10 27789.27 27816.51
D 7 10.00 535.00 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
3653 50050.76 118997.23 0.00
Other 0 0.00 0.00 0.00
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Total 6146 102001.29 209030.68 89525.69