CMS/EIP Fiscal Report Center: 01
Services beginning 01/01/2010 ending 03/31/2010 Date of Report:05/17/2010 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 910 456.25 16881.25 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 906 1053.75 38970.25 36.98
TCM-T1017TL-TARGETED CASE MANAGEMENT 1043 2912.50 107531.25 36.92
Subtotal (Total Children Is Unduplicated) 1889 4422.50 163382.75 36.94
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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 102 203.00 10150.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.50 262.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 8.00 600.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 24 32.00 2400.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 3.00 225.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 7.50 562.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 26 36.50 2025.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 12.00 900.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 2 2.00 97.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 3 2.25 107.50 47.78
SPCH-92506-SPEECH EVAL BY LICENSED SLP 9 10.00 485.00 48.50
Subtotal (Total Children Is Unduplicated) 160 339.75 18703.09 55.05
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 12 59.00 10173.58 172.43
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 59 81.75 4087.50 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 1 1.00 50.00 50.00
CONPP-CONPP-CONSULT, PT, PHONE 2 2.25 56.25 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 10 10.25 512.50 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 5 2.75 68.75 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 26 171.75 4873.75 28.38
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 32 236.50 11825.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 349 2221.75 110891.34 49.91
INTR-INTR-INTERPRETER 96 431.75 15721.72 36.41
OCCT-97530-OT SESSION BY LICENSED OT 32 127.50 8514.86 66.78
PHY-97110-PT SESSION BY LICENSED PT 106 593.61 39387.04 66.35
PHY-97110HM-PT SESSION BY PT ASST 2 9.00 488.88 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 225 1204.50 80269.26 66.64
SPL-92508-GROUP SPL SESSION PER CHILD 2 3.50 46.20 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1171 277525 139269.00 0.50
Subtotal (Total Children Is Unduplicated) 1282 282824 429353.07 1.52
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Total 287586.61 611438.91 2.13
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Number of Children (Unduplicated) With at Least One Service 2332
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Center 01
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 5418 158807.61 236795.79 236904.43
D 0 0.00 0.00 0.00
S 95 97.50 3607.50 0.00
H 0 0.00 0.00 0.00
T 3478 90861.50 164539.24 165246.07
7118 6910.25 166937.43 0.00
Other 1139 30909.75 39558.95 220.00
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Total 17248 287586.61 611438.91 402370.50