CMS/EIP Fiscal Report Center: 01
Services beginning 01/01/2010 ending 03/31/2010 Date of Report:05/17/2010 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 910 456.25 16881.25 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 906 1053.75 38970.25 36.98
TCM-T1017TL-TARGETED CASE MANAGEMENT 2513 7518.50 277749.75 36.94
Subtotal (Total Children Is Unduplicated) 2551 9028.50 333601.25 36.95
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 7 12.00 558.50 46.54
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.00 8.28 8.28
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.00 10.38 10.38
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.00 21.79 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.00 27.19 27.19
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 2.00 93.60 46.80
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 1.00 119.60 119.60
EXIT-EXIT-TRANSITION ASSESSMENT 103 205.00 10250.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 37 52.50 3937.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 6.50 487.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 7.50 562.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 43 85.00 6337.50 74.56
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 10 18.00 999.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 376 491.50 36825.00 74.92
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 57 76.50 5737.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 87 95.50 7162.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 375 507.00 28083.00 55.39
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 194 266.00 19920.75 74.89
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 1 2.00 145.56 72.78
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 2 2.00 97.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 7 7.00 339.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 5 5.00 242.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 7 7.00 339.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 24 32.00 1552.00 48.50
Subtotal (Total Children Is Unduplicated) 718 1885.00 123858.15 65.71
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 14 70.00 12688.61 181.27
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 64 95.25 4762.50 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 8 5.25 131.25 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 10 8.00 400.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 8 4.25 106.25 25.00
CONOP-CONOP-CONSULT, OT, PHONE 1 0.50 12.50 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 3 3.50 175.00 50.00
CONPP-CONPP-CONSULT, PT, PHONE 2 2.25 56.25 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 23 42.75 2137.50 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 5 2.75 68.75 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 34 263.75 7173.75 27.20
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 32 236.50 11825.00 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 33 274.00 13700.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 671 4812.00 240553.33 49.99
INTR-INTR-INTERPRETER 96 431.75 15721.72 36.41
OCCT-97530-OT SESSION BY LICENSED OT 57 274.75 18799.50 68.42
OCCT-97530HM-OT SESSION BY OT ASST 2 3.00 176.52 58.84
PHY-97110-PT SESSION BY LICENSED PT 176 1186.00 80518.50 67.89
PHY-97110HM-PT SESSION BY PT ASST 3 14.00 760.48 54.32
RSPT-RSPT-RESPITE 1 89.50 716.00 8.00
SENS-V5014-HEARING AID REPAIR BY MANUFACTURER 1 1.00 114.00 114.00
SENS-V5264-EARMOLD 1 2.00 37.44 18.72
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 4 32.00 1600.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 411 2499.75 169557.24 67.83
SPL-92508-GROUP SPL SESSION PER CHILD 9 33.00 435.60 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1172 277646 139329.50 0.50
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 8 52.00 2600.00 50.00
Subtotal (Total Children Is Unduplicated) 1328 288086 724157.19 2.51
----------------------------------------------------------------------------------------------------------------
Total 298999.00 1181616.59 3.95
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 2721
----------------------------------------------------------------------------------------------------------------
Center 01
Flag Claims Units Chgs Paid
-------------------------------------------------
R 37 22.50 832.50 0.00
U 0 0.00 0.00 0.00
B 1945 1272.25 49395.75 277.50
P 9408 161668.86 347522.97 346555.94
D 299 296.00 15851.25 0.00
S 934 703.00 26108.75 0.00
H 15 25.50 1695.56 0.00
T 3478 90861.50 164539.24 165246.07
8742 10357.39 352844.55 507.28
Other 3587 33792.00 222826.02 312.50
-------------------------------------------------
Total 28445 298999.00 1181616.59 512899.29