CMS/EIP Fiscal Report Center: 02
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 222 84.75 3117.25 36.78
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 149 149.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 232 361.75 13273.75 36.69
TCM-T1017TL-TARGETED CASE MANAGEMENT 195 478.25 17473.25 36.54
TCON-TCON-TRANSITION CONFERENCE 28 28.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 494 1101.75 33864.25 30.74
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.00 230.00 115.00
EVAL-EVAL-DEVELOPMENTAL EVALUATION 5 6.00 300.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 34 62.00 3100.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.00 150.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.00 300.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.00 111.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 25 46.50 3487.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 13 24.00 1800.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 20 37.00 2053.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 17.00 1275.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.00 21.77 21.77
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 3 3.00 145.50 48.50
Subtotal (Total Children Is Unduplicated) 86 207.50 13022.77 62.76
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 8 11.00 1945.59 176.87
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 14 16.50 825.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 23 18.50 925.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 4 3.00 75.00 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 20 16.00 800.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 11 10.50 525.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 1 0.50 12.50 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 70 441.50 22075.00 50.00
INTR-INTR-INTERPRETER 6 38.50 1797.50 46.69
OCCT-97530-OT SESSION BY LICENSED OT 29 140.25 9347.07 66.65
PHY-97110-PT SESSION BY LICENSED PT 15 71.50 3651.69 51.07
PHY-97110HM-PT SESSION BY PT ASST 1 0.75 31.25 41.67
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 1 2.00 1000.00 500.00
SENS-V5264-EARMOLD 1 2.00 36.00 18.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 54 372.00 24781.98 66.62
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 363 86719.0 43359.50 0.50
Subtotal (Total Children Is Unduplicated) 370 87863.5 111188.08 1.27
----------------------------------------------------------------------------------------------------------------
Total 89172.75 158075.10 1.77
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 645
----------------------------------------------------------------------------------------------------------------
Center 02
Flag Claims Units Chgs Paid
-------------------------------------------------
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 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 1195 51133.25 68410.12 68410.10
2205 38039.50 89664.98 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 3400 89172.75 158075.10 68410.10