CMS/EIP Fiscal Report Center: 01
Services beginning 04/01/2010 ending 06/30/2010 Date of Report:08/18/2010 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 1195 546.50 20195.00 36.95
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 888 922.75 34141.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1022 2994.75 110713.25 36.97
Subtotal (Total Children Is Unduplicated) 2111 4464.00 165050.00 36.97
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 4 4.00 194.00 48.50
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 2.00 17.66 8.83
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) 1 2.00 108.76 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.00 56.56 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 2.00 58.91 29.46
EXIT-EXIT-TRANSITION ASSESSMENT 137 285.50 14275.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.50 262.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 7.50 562.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 2.50 138.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 36 47.50 3562.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 5.50 412.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 3.00 225.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 33 47.00 2608.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 10.50 787.50 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.00 48.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 3.00 145.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 2 3.00 115.72 38.57
PSTH-97001-EVAL BY LICENSED PT, INITIAL 7 8.00 359.17 44.90
SPCH-92506-SPEECH EVAL BY LICENSED SLP 13 13.00 630.50 48.50
Subtotal (Total Children Is Unduplicated) 209 458.50 24656.81 53.78
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 6 17.00 2925.95 172.11
AUD-HA_FUP-AUDIOLOGY SERVICES 1 1.00 50.00 50.00
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 99 133.75 6687.50 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 6 2.50 62.50 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 18 19.75 987.50 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 12 5.50 137.50 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 3 4.00 200.00 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 5 3.75 187.50 50.00
CONPP-CONPP-CONSULT, PT, PHONE 3 1.25 31.25 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 16 19.50 975.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 8 7.25 181.25 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 31 203.50 6032.50 29.64
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 45 364.25 18212.50 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 348 2078.00 101738.60 48.96
INTR-INTR-INTERPRETER 112 482.75 15182.78 31.45
OCCT-97530-OT SESSION BY LICENSED OT 45 244.00 16119.07 66.06
PHY-97110-PT SESSION BY LICENSED PT 91 447.00 29233.60 65.40
RSPT-RSPT-RESPITE 1 78.00 624.00 8.00
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 14 73.00 3650.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 261 1687.25 112182.22 66.49
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1253 301809 150902.00 0.50
Subtotal (Total Children Is Unduplicated) 1347 307682 466303.22 1.52
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Total 312604.50 656010.03 2.10
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Number of Children (Unduplicated) With at Least One Service 2462
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Center 01
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 3378 84900.00 115018.59 114824.96
D 1 0.50 12.50 0.00
S 6 6.25 322.50 0.00
H 4440 101532.25 139863.95 139863.95
T 4976 103643.25 198947.12 198947.12
7746 6865.50 171964.57 0.00
Other 603 15656.75 29880.80 132.07
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Total 21150 312604.50 656010.03 453768.10