CMS/EIP Fiscal Report Center: 10
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 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 1018 3540.00 130980.00 37.00
TCON-TCON-TRANSITION CONFERENCE 236 236.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1729 5613.50 164224.50 29.26
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 18 18.00 191.16 10.62
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 3 3.00 48.90 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 20 21.00 184.37 8.78
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 22 23.00 230.74 10.03
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.00 8.44 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 22 23.00 486.30 21.14
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.00 6.84 6.84
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 18 18.00 506.69 28.15
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
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 8 14.50 1087.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 5.00 375.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 2.50 187.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.00 150.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 7 13.00 721.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 59 98.00 7350.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 38 65.50 4912.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 26 39.00 2925.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 54 94.50 5244.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 37 43.00 3225.00 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 8 8.00 388.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 3 3.00 145.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 7 7.00 339.50 48.50
Subtotal (Total Children Is Unduplicated) 144 506.00 28990.19 57.29
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 7 40.00 1351.27 33.78
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 129 147.00 7350.00 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 17 80.00 2000.00 25.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 2 8.00 400.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 158 1709.75 85487.50 50.00
INTR-INTR-INTERPRETER 1 2.00 100.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 109 502.75 32653.16 64.95
OCCT-97530HM-OT SESSION BY OT ASST 13 35.50 1848.56 52.07
PHY-97110-PT SESSION BY LICENSED PT 121 476.00 30808.08 64.72
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
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 286 1354.75 90581.31 66.86
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 29 66.00 3585.12 54.32
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 545 123540 61770.00 0.50
Subtotal (Total Children Is Unduplicated) 736 128023 321633.44 2.51
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Total 134142.25 514848.13 3.84
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Number of Children (Unduplicated) With at Least One Service 1867
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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 4226 128151.75 324444.88 324444.88
D 65 37.25 1624.75 1624.75
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
8032 5953.25 188778.50 0.00
Other 0 0.00 0.00 0.00
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Total 12323 134142.25 514848.13 326069.63