CMS/EIP Fiscal Report Center: 10
Services beginning 01/01/2010 ending 03/31/2010 Date of Report:05/17/2010 Page: 1
Agency Filter:EXT
Eligibility Filter:Part C (excluding not eligible)
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 21 21.00 227.27 10.82
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 7 7.00 114.10 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 26 28.00 242.33 8.65
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 26 30.00 299.91 10.00
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.00 8.44 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 26 29.00 610.12 21.04
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 2.00 54.38 27.19
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 17 18.00 480.76 26.71
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.00 45.00 45.00
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.00 230.00 115.00
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 0.75 37.50 50.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 26 28.00 1359.50 48.55
PSTH-97001-EVAL BY LICENSED PT, INITIAL 5 5.00 242.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 16 17.00 824.50 48.50
Subtotal (Total Children Is Unduplicated) 73 189.75 4776.31 25.17
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 7 72.00 5487.03 76.21
AUD-HA_FUP-AUDIOLOGY SERVICES 1 1.00 50.00 50.00
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 132 159.00 7950.00 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 1 0.50 12.50 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 2 1.75 87.50 50.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 23 21.25 1062.50 50.00
CONOP-CONOP-CONSULT, OT, PHONE 1 0.25 6.25 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 2 1.50 75.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 31 25.50 1275.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 7 4.25 106.25 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 26 123.00 3075.00 25.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 5 15.00 750.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 300 2951.00 147550.00 50.00
HERN-EIIF_NM-EI HEARING SERVICES AFTER SHINE NONMED 3 7.25 362.50 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 7 11.25 562.50 50.00
INTR-INTR-INTERPRETER 1 2.00 100.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 279 1460.75 97091.86 66.47
OCCT-97530HM-OT SESSION BY OT ASST 22 61.25 3245.62 52.99
PHY-97110-PT SESSION BY LICENSED PT 399 1671.00 111193.95 66.54
PHY-97110HM-PT SESSION BY PT ASST 1 1.00 54.32 54.32
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 1 2.00 1000.00 500.00
SENS-V5264-EARMOLD 2 4.00 73.44 18.36
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 11 10.50 525.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 559 2466.25 165344.14 67.04
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 49 116.50 6347.64 54.49
SPL-92508-GROUP SPL SESSION PER CHILD 1 2.00 26.40 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 545 123540 61770.00 0.50
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 17 70.50 3525.00 50.00
Subtotal (Total Children Is Unduplicated) 985 132802 618709.40 4.66
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Total 132992.00 623485.71 4.69
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Number of Children (Unduplicated) With at Least One Service 993
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Center 10
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 4212 128137.75 324253.68 324215.18
D 0 0.00 0.00 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
2596 4854.25 299232.03 0.00
Other 0 0.00 0.00 0.00
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Total 6808 132992.00 623485.71 324215.18