CMS/EIP Fiscal Report Center: 54
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 305 120.50 4458.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 152 158.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 536 689.75 25419.00 36.85
TCM-T1017TL-TARGETED CASE MANAGEMENT 548 1661.75 61207.25 36.83
TCON-TCON-TRANSITION CONFERENCE 1 1.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1005 2631.00 91084.75 34.62
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 2 2.00 17.66 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 9 9.00 97.20 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 7 7.00 152.53 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 7 6.29 177.70 28.25
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.00 31.81 31.81
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.00 46.80 46.80
AUDE-V5090-DISPENSING FEE PER HEARING AID 2 2.00 239.20 119.60
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 2 2.00 250.00 125.00
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 0.50 25.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 12 32.75 1637.50 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 9.82 735.86 74.93
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 3.50 262.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 1.50 112.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 5.00 375.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 15 19.50 1082.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 22 37.80 2834.98 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 27 39.60 2970.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.50 112.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 40 64.50 3579.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 23 36.16 2711.27 74.98
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.00 48.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 11 11.00 533.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 3 2.08 100.50 48.32
SPCH-92506-SPEECH EVAL BY LICENSED SLP 14 13.31 645.13 48.47
Subtotal (Total Children Is Unduplicated) 153 309.81 18779.64 60.62
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 4 3.50 175.00 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 1 0.50 12.50 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 54 49.00 2450.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 4 2.50 62.50 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 21 19.50 975.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 2 1.50 37.50 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 4 2.50 125.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 56 49.25 2462.50 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 3 1.00 25.00 25.00
ECE-ECE-EARLY CHILDHOOD EDUCATION 1 54.40 680.00 12.50
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 11 110.50 5525.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 131 1100.25 55012.50 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 3 6.00 300.00 50.00
INTR-INTR-INTERPRETER 18 96.50 4825.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 107 578.16 39213.14 67.82
OCCT-97530HM-OT SESSION BY OT ASST 1 0.20 10.78 53.90
PHY-97110-PT SESSION BY LICENSED PT 40 244.48 16591.01 67.86
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 3 3.00 150.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 127 776.55 52705.47 67.87
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 5 18.00 977.76 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 1 2.00 26.40 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 772 187830 132054.85 0.70
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 6 8.00 400.00 50.00
Subtotal (Total Children Is Unduplicated) 833 190957 314796.91 1.65
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Total 193898.10 424661.30 2.19
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Number of Children (Unduplicated) With at Least One Service 1202
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Center 54
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 2791 144626.40 284895.26 284895.26
D 74 47.00 1763.25 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
4557 49224.70 138002.79 0.00
Other 0 0.00 0.00 0.00
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Total 7422 193898.10 424661.30 284895.26