CMS/EIP Fiscal Report Center: 06
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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 431 230.50 8528.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 639 662.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 434 406.25 15031.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1847 5690.50 210548.50 37.00
TCON-TCON-TRANSITION CONFERENCE 155 155.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1856 7144.25 234108.25 32.77
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 1.00 48.50 48.50
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 100 101.00 891.83 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 97 98.00 1058.40 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 95 96.00 2091.84 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 3.00 84.84 28.28
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 5.00 375.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 7.50 562.50 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 238 332.00 24900.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 225 306.50 22937.58 74.84
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 10 17.00 943.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 18 30.50 2287.50 75.00
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 2 2.00 54.44 27.22
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 25 25.00 1431.75 57.27
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 4 4.00 194.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.00 97.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 2 2.00 97.00 48.50
Subtotal (Total Children Is Unduplicated) 386 1032.50 58055.68 56.23
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 3 3.00 840.04 280.01
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 13 9.50 475.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 0.50 25.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 1 0.50 12.50 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 11 16.50 825.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 3 1.00 25.00 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 6 5.75 287.50 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 5 4.50 225.00 50.00
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 5 38.00 1900.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 275 1785.25 85550.00 47.92
INTR-INTR-INTERPRETER 30 96.00 5480.00 57.08
OCCT-97530-OT SESSION BY LICENSED OT 113 568.00 37829.00 66.60
OCCT-97530HM-OT SESSION BY OT ASST 7 13.00 706.16 54.32
PHY-97110-PT SESSION BY LICENSED PT 198 1019.25 67032.65 65.77
PHY-97110HM-PT SESSION BY PT ASST 7 24.50 1302.44 53.16
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 609 3700.50 233937.51 63.22
SPL-92508-GROUP SPL SESSION PER CHILD 8 12.50 164.12 13.13
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 733 137630 68814.00 0.50
Subtotal (Total Children Is Unduplicated) 946 144928 505430.92 3.49
----------------------------------------------------------------------------------------------------------------
Total 153105.00 797594.85 5.21
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1908
----------------------------------------------------------------------------------------------------------------
Center 06
Flag Claims Units Chgs Paid
-------------------------------------------------
R 26 15.25 564.25 0.00
U 0 0.00 0.00 0.00
B 192 121.50 4495.50 434.75
P 8488 63887.00 212565.20 212597.32
D 0 0.00 0.00 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
18449 89081.25 579969.90 1530.94
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 27155 153105.00 797594.85 214563.01