CMS/EIP Fiscal Report Center: 07
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 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 877 2337.50 86487.50 37.00
TCON-TCON-TRANSITION CONFERENCE 30 31.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1639 4537.00 156991.00 34.60
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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 2 4.00 300.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.00 300.00 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 27 47.00 3516.74 74.82
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 14.00 1050.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 4.00 300.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 49 90.00 4995.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 86 237.50 17775.00 74.84
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 5 5.00 363.90 72.78
NUTR-97802-NUTRITIONAL EVAL, INITIAL 1 0.75 37.50 50.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.00 27.40 27.40
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 20 20.00 855.72 42.79
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.00 26.94 26.94
PSTH-97001-EVAL BY LICENSED PT, INITIAL 8 8.00 259.50 32.44
SCREEN-T1023-INTERDISCIPLINARY SCREENING 11 12.00 600.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 49 50.00 2304.84 46.10
Subtotal (Total Children Is Unduplicated) 229 559.25 35401.94 63.30
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.00 524.40 524.40
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 245 1580.50 79024.57 50.00
INTR-INTR-INTERPRETER 1 6.00 300.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 74 465.25 29753.38 63.95
OCCT-97530HM-OT SESSION BY OT ASST 3 7.00 380.24 54.32
PHY-97110-PT SESSION BY LICENSED PT 60 337.00 21541.15 63.92
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 280 1881.00 122826.41 65.30
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 669 113789 56887.00 0.50
Subtotal (Total Children Is Unduplicated) 944 118208 318155.90 2.69
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Total 123304.00 510548.84 4.14
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Number of Children (Unduplicated) With at Least One Service 1780
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Center 07
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 3375 114592.00 331510.94 331490.94
D 39 18.25 675.25 0.00
S 1 2.00 74.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
8856 8691.75 178288.65 0.00
Other 0 0.00 0.00 0.00
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Total 12271 123304.00 510548.84 331490.94