CMS/EIP Fiscal Report Center: 06
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 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 958 2864.50 105986.50 37.00
TCON-TCON-TRANSITION CONFERENCE 155 155.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1445 4318.25 129546.25 30.00
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 1.00 48.50 48.50
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 15 15.00 132.45 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 15 15.00 162.00 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 15 15.00 326.85 21.79
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 12 17.50 1312.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 12 19.50 1412.58 72.44
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 5.50 305.25 55.50
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 1 1.00 27.22 27.22
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.00 57.27 57.27
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 31 92.50 3881.62 41.96
----------------------------------------------------------------------------------------------------------------
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 156 1041.25 48350.00 46.43
INTR-INTR-INTERPRETER 30 96.00 5480.00 57.08
OCCT-97530-OT SESSION BY LICENSED OT 58 179.50 10015.13 55.79
OCCT-97530HM-OT SESSION BY OT ASST 3 3.50 190.12 54.32
PHY-97110-PT SESSION BY LICENSED PT 107 490.75 31220.45 63.62
PHY-97110HM-PT SESSION BY PT ASST 1 1.00 25.92 25.92
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 414 2267.50 139069.63 61.33
SPL-92508-GROUP SPL SESSION PER CHILD 1 0.50 5.72 11.44
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 733 137605 68801.50 0.50
Subtotal (Total Children Is Unduplicated) 911 141764 307773.51 2.17
----------------------------------------------------------------------------------------------------------------
Total 146175.00 441201.38 3.02
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1614
----------------------------------------------------------------------------------------------------------------
Center 06
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 4595 61385.00 119478.20 119510.32
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
13471 84790.00 321723.18 1305.94
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 18066 146175.00 441201.38 120816.26