CMS/EIP Fiscal Report Center: 07
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 1272 920.75 34067.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 256 263.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 704 984.75 36435.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1748 5258.50 194444.25 36.98
TCON-TCON-TRANSITION CONFERENCE 30 31.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1860 7458.00 264947.75 35.53
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 1.00 48.50 48.50
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 2 2.00 17.66 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-92588-OTOACOUSTIC EMISSIONS (COMP) 2 2.00 63.62 31.81
EVAL-EVAL-DEVELOPMENTAL EVALUATION 3 5.00 175.00 35.00
EXIT-EXIT-TRANSITION ASSESSMENT 27 44.00 2200.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 10.00 750.00 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 8 24.00 1800.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 12.00 666.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 50 88.00 6591.74 74.91
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 18 34.00 2550.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 14 19.50 1462.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 119 220.00 12210.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 190 505.00 37762.50 74.78
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 7 7.00 509.46 72.78
NUTR-97802-NUTRITIONAL EVAL, INITIAL 1 0.75 37.50 50.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 6 6.00 269.90 44.98
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 25 25.00 1098.22 43.93
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.00 26.94 26.94
PSTH-97001-EVAL BY LICENSED PT, INITIAL 10 10.00 356.50 35.65
SCREEN-T1023-INTERDISCIPLINARY SCREENING 56 57.00 2850.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 68 69.00 3226.34 46.76
Subtotal (Total Children Is Unduplicated) 425 1148.25 74821.00 65.16
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 3 4.00 2141.65 535.41
AUD-HA_FUP-AUDIOLOGY SERVICES 1 1.00 50.00 50.00
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 19 25.00 1250.00 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 3 1.50 37.50 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 12 14.75 737.50 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 2 0.75 18.75 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 26 39.00 1950.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 2 1.25 31.25 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 19 24.00 1200.00 50.00
CONPP-CONPP-CONSULT, PT, PHONE 1 0.50 12.50 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 21 32.00 1600.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 2 1.25 31.25 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 572 3836.50 191824.57 50.00
INTR-INTR-INTERPRETER 1 6.00 300.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 119 812.50 53324.71 65.63
OCCT-97530HM-OT SESSION BY OT ASST 3 7.00 380.24 54.32
PHY-97110-PT SESSION BY LICENSED PT 91 576.75 37815.38 65.57
PHY-97110HM-PT SESSION BY PT ASST 1 1.00 54.32 54.32
SENS-V5264-EARMOLD 2 3.00 56.16 18.72
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 3 3.00 150.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 363 2358.50 155239.11 65.82
SPL-92508-GROUP SPL SESSION PER CHILD 1 0.50 6.60 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 669 117689 58837.00 0.50
Subtotal (Total Children Is Unduplicated) 1033 125439 507048.49 4.04
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Total 134045.00 846817.24 6.32
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Number of Children (Unduplicated) With at Least One Service 1933
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Center 07
Flag Claims Units Chgs Paid
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R 244 157.00 5809.00 0.00
U 0 0.00 0.00 0.00
B 4277 2844.00 115340.81 0.00
P 3781 114961.75 348801.22 348781.22
D 39 18.25 675.25 0.00
S 6 7.25 268.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
10224 16056.75 375922.71 0.00
Other 0 0.00 0.00 0.00
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Total 18571 134045.00 846817.24 348781.22