CMS/EIP Fiscal Report Center: 06
Services beginning 01/01/2010 ending 03/31/2010 Date of Report:05/17/2010 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 459 253.75 9388.75 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 948 3126.50 115680.50 37.00
TCON-TCON-TRANSITION CONFERENCE 218 220.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1475 4791.25 141275.25 29.49
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 13 13.00 114.79 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 12 12.00 129.60 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 12 12.00 261.48 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.00 28.28 28.28
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 17 28.00 2100.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 17 28.00 2100.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.00 222.00 55.50
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.00 57.27 57.27
Subtotal (Total Children Is Unduplicated) 24 99.00 5013.42 50.64
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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 8 33.50 437.50 13.06
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 139 1030.25 51512.50 50.00
INTR-INTR-INTERPRETER 13 44.00 2517.00 57.20
OCCT-97530-OT SESSION BY LICENSED OT 60 217.00 12498.62 57.60
OCCT-97530HM-OT SESSION BY OT ASST 4 10.00 457.44 45.74
PHY-97110-PT SESSION BY LICENSED PT 110 420.75 27019.33 64.22
PHY-97110HM-PT SESSION BY PT ASST 2 1.75 37.39 21.37
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 438 2247.50 142563.15 63.43
SPL-92508-GROUP SPL SESSION PER CHILD 2 2.50 -17.20 0.00
TRAN-TRAN-FAMILY TRANSPORTATION 1 1.00 40.00 40.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 773 145779 73147.25 0.50
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 1 30.00 15.00 0.50
Subtotal (Total Children Is Unduplicated) 890 149877 313256.97 2.09
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Total 154766.75 459545.64 2.97
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Number of Children (Unduplicated) With at Least One Service 1616
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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 0 0.00 0.00 0.00
P 5325 65510.75 136089.41 136089.41
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
13735 89255.25 323405.32 3066.65
Other 0 0.00 0.00 0.00
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Total 19061 154766.75 459545.64 139156.06