CMS/EIP Fiscal Report Center: 06
Services beginning 04/01/2010 ending 06/30/2010 Date of Report:08/18/2010 Page: 1
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 473 287.00 10619.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 653 705.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 602 560.00 20720.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1864 6510.50 240842.25 36.99
TCON-TCON-TRANSITION CONFERENCE 173 174.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1868 8236.50 272181.25 33.05
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 121 121.00 1068.43 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 123 123.00 1328.40 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 116 116.00 2527.64 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.00 56.56 28.28
EXIT-EXIT-TRANSITION ASSESSMENT 1 1.00 50.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 6.50 487.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 6 10.50 787.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.00 300.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.50 83.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 198 268.00 20013.61 74.68
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 222 329.50 24712.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 11 18.00 999.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 35 51.00 3825.00 75.00
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 6 6.00 163.32 27.22
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 25 25.00 1431.75 57.27
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 4 4.00 194.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 9 9.00 436.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 6 6.00 291.00 48.50
Subtotal (Total Children Is Unduplicated) 345 1102.00 58755.96 53.32
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 6 6.00 969.26 161.54
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 11 9.00 375.00 41.67
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 4 3.75 187.50 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 1 0.50 12.50 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 4 5.25 227.50 43.33
CONOP-CONOP-CONSULT, OT, PHONE 1 0.50 12.50 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 3 4.00 200.00 50.00
CONPP-CONPP-CONSULT, PT, PHONE 1 0.50 12.50 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 3 3.00 150.00 50.00
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 9 43.75 2175.00 49.71
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 4.00 200.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 296 2044.75 102237.50 50.00
INTR-INTR-INTERPRETER 44 163.00 9212.50 56.52
OCCT-97530-OT SESSION BY LICENSED OT 127 575.50 36463.46 63.36
OCCT-97530HM-OT SESSION BY OT ASST 9 31.00 1598.16 51.55
PHY-97110-PT SESSION BY LICENSED PT 194 1041.00 66356.60 63.74
PHY-97110HM-PT SESSION BY PT ASST 2 10.50 570.36 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 595 3723.75 239832.92 64.41
SPL-92508-GROUP SPL SESSION PER CHILD 28 492.00 6494.40 13.20
TRAN-TRAN-FAMILY TRANSPORTATION 3 60.00 109.00 1.82
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 778 146396 73589.75 0.50
Subtotal (Total Children Is Unduplicated) 948 154618 540986.41 3.50
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Total 163956.25 871923.62 5.32
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Number of Children (Unduplicated) With at Least One Service 1915
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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 4207 2787.75 103146.75 18.50
P 732 2785.25 18770.99 18837.73
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 0 0.00 0.00 0.00
25212 158383.25 750005.88 212.75
Other 0 0.00 0.00 0.00
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Total 30151 163956.25 871923.62 19068.98