CMS/EIP Fiscal Report Center: 06
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 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 960 3261.75 120638.50 36.99
TCON-TCON-TRANSITION CONFERENCE 173 174.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1511 4987.75 151977.50 30.47
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 16 16.00 141.28 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 16 16.00 172.80 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 16 16.00 348.64 21.79
EXIT-EXIT-TRANSITION ASSESSMENT 1 1.00 50.00 50.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 14 20.00 1413.61 70.68
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 17 26.50 1987.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 5.00 277.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 6.00 450.00 75.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 3 3.00 171.81 57.27
Subtotal (Total Children Is Unduplicated) 33 109.50 5013.14 45.78
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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 159 1171.25 58562.50 50.00
INTR-INTR-INTERPRETER 44 163.00 9212.50 56.52
OCCT-97530-OT SESSION BY LICENSED OT 73 303.25 17983.13 59.30
OCCT-97530HM-OT SESSION BY OT ASST 7 28.00 1435.20 51.26
PHY-97110-PT SESSION BY LICENSED PT 100 445.75 26366.69 59.15
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 405 2381.75 148737.96 62.45
SPL-92508-GROUP SPL SESSION PER CHILD 13 214.50 2831.40 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) 921 151244 343349.89 2.27
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Total 156341.00 500340.53 3.20
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Number of Children (Unduplicated) With at Least One Service 1641
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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 0 0.00 0.00 0.00
P 244 2466.50 6946.36 7080.98
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
20136 153874.50 493394.17 212.75
Other 0 0.00 0.00 0.00
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Total 20380 156341.00 500340.53 7293.73