CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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 928 460.00 17020.00 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 894 1040.50 38498.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1231 3031.25 112119.25 36.99
Subtotal (Total Children Is Unduplicated) 2009 4531.75 167637.75 36.99
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 4 7.00 316.00 45.14
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.00 8.83 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.00 21.60 10.80
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.00 8.44 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.00 43.58 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.00 56.56 28.28
EXIT-EXIT-TRANSITION ASSESSMENT 95 189.00 9450.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 9.00 675.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.50 112.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.00 225.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.00 111.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 18 31.50 2362.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 2.00 150.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 7.00 525.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 14 24.00 1332.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 17.50 1312.50 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 4 4.00 194.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 3 2.75 131.52 47.83
PSTH-97001-EVAL BY LICENSED PT, INITIAL 4 5.00 242.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 10 16.00 776.00 48.50
Subtotal (Total Children Is Unduplicated) 152 329.25 18054.53 54.84
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 8 26.00 3175.89 122.15
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 74 101.25 5062.50 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 3 0.75 18.75 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 8 5.25 262.50 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 4 2.75 68.75 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 1.00 50.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 1 0.25 6.25 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.00 50.00 50.00
CONPP-CONPP-CONSULT, PT, PHONE 2 1.00 25.00 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 20 16.00 800.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 9 6.00 150.00 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 28 133.00 3870.00 29.10
EIIF-90847-FAMILY PSYCHOTHERAPY WITH PATIENT 1 5.00 306.35 61.27
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 16 73.50 3675.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 351 2126.00 105738.50 49.74
INTR-INTR-INTERPRETER 86 464.75 14585.00 31.38
OCCT-97530-OT SESSION BY LICENSED OT 35 153.00 10367.46 67.76
OCCT-97530HM-OT SESSION BY OT ASST 2 2.50 135.80 54.32
PHY-97110-PT SESSION BY LICENSED PT 101 392.25 24724.10 63.03
PHY-97110HM-PT SESSION BY PT ASST 2 4.00 217.28 54.32
RSPT-RSPT-RESPITE 1 77.50 620.00 8.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 311 1598.00 107259.12 67.12
SPL-92508-GROUP SPL SESSION PER CHILD 17 41.25 543.36 13.17
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1157 266529 133173.00 0.50
Subtotal (Total Children Is Unduplicated) 1254 271761 414884.61 1.53
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Total 276622.00 600576.89 2.17
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Number of Children (Unduplicated) With at Least One Service 2373
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Center 01
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 5845 157002.25 225611.22 225661.22
D 12 20.00 1322.00 0.00
S 247 215.50 7973.50 0.00
H 0 0.00 0.00 0.00
T 3603 99995.50 162350.02 162350.02
7645 9416.25 184303.87 0.00
Other 427 9972.50 19016.28 0.00
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Total 17779 276622.00 600576.89 388011.24