CMS/EIP Fiscal Report Center: 10
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 14 7.75 286.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 878 939.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 829 890.75 32957.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 2419 8583.50 317589.50 37.00
TCON-TCON-TRANSITION CONFERENCE 236 236.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 2425 10657.0 350834.00 32.92
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 24 24.00 259.13 10.80
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 7 7.00 114.10 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 29 31.00 268.82 8.67
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 29 33.00 331.05 10.03
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.00 8.44 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 29 32.00 675.49 21.11
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 2.00 54.38 27.19
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 20 21.00 565.60 26.93
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
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 45 82.00 6150.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 18 33.00 2475.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 13 22.00 1650.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 10 18.00 1350.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 33 62.50 3468.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 307 527.50 39562.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 217 369.00 27675.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 133 215.50 16162.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 363 651.50 36158.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 215 263.00 19725.00 75.00
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) 681 2448.75 159393.01 65.09
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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 145908.00 1128936.41 7.74
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Number of Children (Unduplicated) With at Least One Service 2467
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Center 10
Flag Claims Units Chgs Paid
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R 3 1.50 55.50 0.00
U 0 0.00 0.00 0.00
B 1548 963.25 36104.00 138.75
P 11418 133398.00 556156.38 555711.89
D 65 37.25 1624.75 1624.75
S 78 54.00 1998.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
10994 11454.00 532997.78 0.00
Other 0 0.00 0.00 0.00
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Total 24106 145908.00 1128936.41 557475.39