CMS/EIP Fiscal Report Center: 06
Services beginning 01/01/2010 ending 03/31/2010 Date of Report:05/17/2010 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 460 254.00 9398.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 712 753.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 481 438.00 16206.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1849 6186.25 228891.25 37.00
TCON-TCON-TRANSITION CONFERENCE 218 220.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1866 7851.25 254495.25 32.41
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 126 126.00 1112.58 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 126 126.00 1360.80 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 123 123.00 2680.17 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 5 5.00 141.40 28.28
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 8 11.50 862.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 6 9.00 675.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 1.00 75.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.50 83.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 268 379.00 28425.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 213 315.00 23625.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 10 18.00 999.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 11 15.50 1162.50 75.00
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 3 3.00 81.66 27.22
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 12 12.00 687.24 57.27
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 4 4.00 194.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 8 8.00 388.00 48.50
Subtotal (Total Children Is Unduplicated) 355 1158.50 62601.60 54.04
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.00 192.74 96.37
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 6 5.25 242.50 46.19
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 2 2.00 100.00 50.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 9 34.50 487.50 14.13
CONOP-CONOP-CONSULT, OT, PHONE 1 0.25 6.25 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 6 7.75 387.50 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 4 3.50 175.00 50.00
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 6 38.50 1925.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 270 1829.25 91462.50 50.00
INTR-INTR-INTERPRETER 13 44.00 2517.00 57.20
OCCT-97530-OT SESSION BY LICENSED OT 101 470.25 30372.72 64.59
OCCT-97530HM-OT SESSION BY OT ASST 10 20.50 1629.00 79.46
PHY-97110-PT SESSION BY LICENSED PT 208 965.25 64173.65 66.48
PHY-97110HM-PT SESSION BY PT ASST 8 14.25 926.71 65.03
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 613 3461.75 224991.65 64.99
SPL-92508-GROUP SPL SESSION PER CHILD 15 204.50 2649.20 12.95
TRAN-TRAN-FAMILY TRANSPORTATION 1 1.00 40.00 40.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 774 145891 73203.25 0.50
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 1 30.00 15.00 0.50
Subtotal (Total Children Is Unduplicated) 920 153026 495497.17 3.24
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Total 162035.25 812594.02 5.01
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Number of Children (Unduplicated) With at Least One Service 1901
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Center 06
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 1646 1033.50 38239.50 231.25
P 8257 67433.00 207212.66 207212.66
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 1 0.75 50.91 0.00
T 0 0.00 0.00 0.00
18489 93568.00 567090.95 3066.65
Other 0 0.00 0.00 0.00
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Total 28393 162035.25 812594.02 210510.56