CMS/EIP Fiscal Report Center: 53
Services beginning 04/01/2010 ending 06/30/2010 Date of Report:08/18/2010 Page: 1
Payclass Filters:GR
Eligibility Filter:Part C (excluding not eligible)
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 215 168.75 6243.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 362 440.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 414 658.75 24373.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 286 744.50 27509.50 36.95
TCON-TCON-TRANSITION CONFERENCE 113 114.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 611 2126.00 58127.00 27.34
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 3 3.00 145.50 48.50
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 2 3.00 26.49 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.00 10.80 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 3.00 65.37 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.00 54.38 54.38
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 3 4.00 127.24 31.81
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 6 6.00 625.00 104.17
EXIT-EXIT-TRANSITION ASSESSMENT 71 136.75 6837.50 50.00
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 3 5.00 277.50 55.50
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 6.50 487.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 4.50 249.75 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 54 106.00 5883.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 11 24.00 1800.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 6.00 450.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 7.50 562.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 29 57.50 3191.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 44 94.00 7050.00 75.00
NUTR-NUTR-UNSPECIFIED NUTRITIONAL EVAL 2 3.00 150.00 50.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 3.00 145.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.00 97.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 16 16.00 776.00 48.50
Subtotal (Total Children Is Unduplicated) 189 492.75 29012.28 58.88
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.00 1337.50 1337.50
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 146 212.00 10600.00 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 30 31.50 787.50 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 5 7.50 375.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 1 0.25 6.25 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 1.00 50.00 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 16 21.75 1087.50 50.00
CONPP-CONPP-CONSULT, PT, PHONE 1 1.00 25.00 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 13 25.00 1250.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 2 101.00 2525.00 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 3 3.00 75.00 25.00
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 29 182.00 9100.00 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 3 7.00 350.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 116 614.00 30700.00 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 3 5.00 250.00 50.00
INTR-INTR-INTERPRETER 6 7.00 350.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 12 54.50 3672.34 67.38
OCCT-97530HM-OT SESSION BY OT ASST 2 4.00 217.28 54.32
PHY-97110-PT SESSION BY LICENSED PT 11 74.50 5057.06 67.88
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 4.00 200.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 30 204.50 13881.46 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 580 114141 57031.50 0.50
Subtotal (Total Children Is Unduplicated) 594 115703 138928.39 1.20
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Total 118321.25 226067.67 1.91
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Number of Children (Unduplicated) With at Least One Service 748
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Center 53
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 1023 30338.50 45939.02 45939.02
D 3 5.00 185.00 185.00
S 0 0.00 0.00 0.00
H 679 21819.75 30446.49 30446.49
T 0 0.00 0.00 0.00
4570 66158.00 149497.16 13.20
Other 0 0.00 0.00 0.00
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Total 6275 118321.25 226067.67 76583.71