CMS/EIP Fiscal Report Center: 54
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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 305 120.50 4458.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 152 158.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 536 689.75 25419.00 36.85
TCM-T1017TL-TARGETED CASE MANAGEMENT 1331 4216.50 155464.75 36.87
TCON-TCON-TRANSITION CONFERENCE 1 1.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1347 5185.75 185342.25 35.74
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 3 3.00 31.86 10.62
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 20 20.00 176.60 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 30 32.00 345.60 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 25 26.00 566.54 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 2 2.00 108.76 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 7 7.00 197.96 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 10 12.00 358.74 29.90
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.00 46.80 46.80
AUDE-V5090-DISPENSING FEE PER HEARING AID 2 2.00 239.20 119.60
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 2 3.00 375.00 125.00
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 0.50 25.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 13 34.50 1725.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 9 14.00 1050.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 13 18.00 1350.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 1.50 112.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 29 39.00 2925.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 37 50.50 2802.75 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 2 4.00 222.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 43 73.50 5512.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 65 98.50 7387.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.50 112.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 108 164.00 9102.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 124 179.00 13425.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 6 6.00 291.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 14 14.00 679.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 3 3.00 145.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 8 8.00 388.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 46 48.00 2328.00 48.50
Subtotal (Total Children Is Unduplicated) 369 865.50 52030.31 60.12
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 4 3.50 175.00 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 1 0.50 12.50 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 55 50.00 2500.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 6 3.25 81.25 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 23 21.75 1087.50 50.00
CONOP-CONOP-CONSULT, OT, PHONE 2 1.50 37.50 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 4 2.50 125.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 57 50.25 2512.50 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 4 2.00 50.00 25.00
ECE-ECE-EARLY CHILDHOOD EDUCATION 1 54.40 680.00 12.50
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.00 25.00 25.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 21 150.00 7512.50 50.08
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 337 2238.50 111912.50 49.99
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 4 9.00 450.00 50.00
INTR-INTR-INTERPRETER 18 96.50 4825.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 149 839.36 56958.29 67.86
OCCT-97530HM-OT SESSION BY OT ASST 2 8.00 434.56 54.32
PHY-97110-PT SESSION BY LICENSED PT 84 437.00 29561.32 67.65
SENS-V5264-EARMOLD 1 1.00 18.72 18.72
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 3 3.00 150.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 255 1398.75 94947.15 67.88
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 8 26.50 1439.48 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 5 16.50 217.80 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 772 189244 133044.65 0.70
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 6 8.00 400.00 50.00
Subtotal (Total Children Is Unduplicated) 868 194667 449158.22 2.31
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Total 200718.01 686530.78 3.42
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Number of Children (Unduplicated) With at Least One Service 1395
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Center 54
Flag Claims Units Chgs Paid
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R 69 66.00 2904.50 0.00
U 0 0.00 0.00 0.00
B 2099 1661.00 70534.93 0.00
P 5143 146341.90 355378.87 355340.99
D 114 75.50 3226.73 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
5638 52573.61 254485.75 0.00
Other 0 0.00 0.00 0.00
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Total 13063 200718.01 686530.78 355340.99