CMS/EIP Fiscal Report Center: 09
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 1102 953.00 35242.50 36.98
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 820 1039.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 830 852.25 31533.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1009 2771.75 102517.75 36.99
TCON-TCON-TRANSITION CONFERENCE 200 200.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1828 5816.00 169293.50 29.11
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Screening, Eval, and Assessment,Class #02
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.00 0.54 0.54
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.00 6.01 6.01
EXIT-EXIT-TRANSITION ASSESSMENT 62 102.50 5125.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 13 20.00 1500.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 6.50 487.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 4.50 337.50 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 6 9.00 499.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 79 139.00 10425.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 17 33.00 2475.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 23 37.00 2676.00 72.32
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 59 103.50 5744.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.00 225.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 2 3.00 145.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 2.00 97.00 48.50
Subtotal (Total Children Is Unduplicated) 170 468.00 29968.80 64.04
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 7.00 1282.98 183.28
AUD-HA_FUP-AUDIOLOGY SERVICES 1 2.00 82.00 41.00
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 124 162.25 8112.50 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 5 2.50 62.50 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 12 18.50 925.00 50.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 42 52.75 2637.50 50.00
CONOP-CONOP-CONSULT, OT, PHONE 2 0.75 18.75 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 12 45.25 2262.50 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 27 97.00 4850.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 213 1738.25 86852.50 49.97
INTR-INTR-INTERPRETER 13 24.00 1200.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 192 1352.50 89719.30 66.34
OCCT-97530HM-OT SESSION BY OT ASST 3 10.75 396.04 36.84
PHY-97110-PT SESSION BY LICENSED PT 146 839.75 55122.22 65.64
PHY-97110HM-PT SESSION BY PT ASST 3 10.00 538.81 53.88
SENS-HA_INS-SENSORY AID INSURANCE PER EAR 2 4.00 260.00 65.00
SENS-V5264-EARMOLD 1 2.00 37.44 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 471 3508.00 236581.74 67.44
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 856 231467 115733.50 0.50
Subtotal (Total Children Is Unduplicated) 1091 239344 606675.28 2.53
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Total 245628.25 805937.58 3.28
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Number of Children (Unduplicated) With at Least One Service 1964
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Center 09
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 1 1.75 64.75 0.00
P 9359 154224.75 495502.39 495737.79
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 5176 81795.00 276694.23 276694.23
819 9606.75 33676.21 298.38
Other 0 0.00 0.00 0.00
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Total 15355 245628.25 805937.58 772730.40