CMS/EIP Fiscal Report Center: 07
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 1182 958.25 35455.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 210 219.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 684 973.00 35964.50 36.96
TCM-T1017TL-TARGETED CASE MANAGEMENT 943 2693.50 99631.75 36.99
TCON-TCON-TRANSITION CONFERENCE 39 39.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1567 4882.75 171051.50 35.03
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 3 3.00 26.05 8.68
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 3 4.00 43.20 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.00 43.58 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 2 2.00 107.66 53.83
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.00 28.28 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.00 31.52 31.52
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 0.75 37.50 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 36 68.00 3400.00 50.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 6 16.00 1200.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 4.00 222.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 34 61.00 4507.50 73.89
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 8.00 600.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 6.50 487.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 65 121.00 6715.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 95 277.50 20812.50 75.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 2 2.00 145.56 72.78
NUTR-97802-NUTRITIONAL EVAL, INITIAL 5 5.25 262.50 50.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 2 2.00 97.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 14 14.00 570.54 40.75
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 10 10.00 485.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 8 8.00 400.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 51 52.00 2522.00 48.50
Subtotal (Total Children Is Unduplicated) 250 670.00 42793.89 63.87
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 2.00 300.00 150.00
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 25 25.50 1275.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 10 9.00 450.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 9 4.50 112.50 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 21 26.50 1325.00 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 19 21.50 1075.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 27 32.75 1637.50 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 4 2.25 56.25 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 236 1504.75 75237.50 50.00
INTR-INTR-INTERPRETER 2 6.00 300.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 70 395.50 24726.08 62.52
OCCT-97530HM-OT SESSION BY OT ASST 2 4.00 217.28 54.32
PHY-97110-PT SESSION BY LICENSED PT 63 362.25 22895.59 63.20
SENS-V5264-EARMOLD 2 3.00 54.72 18.24
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 1.00 50.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 266 1713.50 111854.05 65.28
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 670 129681 64808.00 0.50
Subtotal (Total Children Is Unduplicated) 927 133795 306374.47 2.29
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Total 139347.75 520219.86 3.73
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Number of Children (Unduplicated) With at Least One Service 1696
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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 3 2.75 101.75 0.00
P 3332 129237.75 321146.05 321146.05
D 14 6.75 249.75 0.00
S 26 9.50 351.50 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
9457 10091.00 198370.81 0.00
Other 0 0.00 0.00 0.00
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Total 12832 139347.75 520219.86 321146.05