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: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 248 182.00 6734.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 412 491.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 495 747.00 27639.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 335 900.75 33290.75 36.96
TCON-TCON-TRANSITION CONFERENCE 115 116.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 713 2436.75 67663.75 27.77
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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 72 138.75 6937.50 50.00
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 4 7.00 388.50 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 72 149.50 8297.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 12 26.00 1950.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 10.00 750.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 13.50 1012.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 43 85.50 4745.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 63 179.00 13425.00 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) 228 665.25 40466.53 60.83
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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 148 214.00 10700.00 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 31 32.50 812.50 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 17 22.75 1137.50 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 30 192.00 9600.00 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 4 19.00 950.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 119 625.00 31250.00 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 3 5.00 250.00 50.00
INTR-INTR-INTERPRETER 7 8.00 400.00 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 644 122182 61052.00 0.50
Subtotal (Total Children Is Unduplicated) 659 123782 144823.89 1.17
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Total 126883.50 252954.17 1.99
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Number of Children (Unduplicated) With at Least One Service 852
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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 1096 32610.50 49259.02 49259.02
D 4 7.00 335.00 185.00
S 0 0.00 0.00 0.00
H 694 22441.75 31400.99 31400.99
T 0 0.00 0.00 0.00
5122 71824.25 171959.16 13.20
Other 0 0.00 0.00 0.00
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Total 6916 126883.50 252954.17 80858.21