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:TPIN
Eligibility Filter:Program Patients
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.00 18.72 18.72
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.00 25.04 25.04
EXIT-EXIT-TRANSITION ASSESSMENT 1 1.00 50.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 22 32.50 2437.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.00 300.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 14 20.50 1537.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 11 14.50 804.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 145 206.00 15450.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 18 25.50 1912.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 33 44.00 3300.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 125 179.00 9934.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 45 66.00 4912.50 74.43
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.00 48.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 0.00 29.78 0.00
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 49.04 49.04
SPCH-92506-SPEECH EVAL BY LICENSED SLP 2 2.00 173.87 86.94
Subtotal (Total Children Is Unduplicated) 211 600.00 41032.70 68.39
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 4 7.00 5605.61 800.80
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 5 7.25 362.50 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 4 2.50 125.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.00 50.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 40 129.00 6523.90 50.57
OCCT-97530-OT SESSION BY LICENSED OT 29 106.75 9120.01 85.43
PHY-97110-PT SESSION BY LICENSED PT 63 342.00 27118.14 79.29
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 116 549.00 41696.31 75.95
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.00 13.20 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 2 28.00 14.00 0.50
Subtotal (Total Children Is Unduplicated) 207 1173.50 90628.67 77.23
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Total 1773.50 131661.37 74.24
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Number of Children (Unduplicated) With at Least One Service 398
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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 5 5.00 339.40 0.00
D 187 248.00 14446.63 0.00
S 4 5.50 412.50 0.00
H 13 20.50 1437.50 0.00
T 0 0.00 0.00 0.00
667 470.25 45456.52 237.58
Other 991 1024.25 69568.82 0.00
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Total 1867 1773.50 131661.37 237.58