CMS/EIP Fiscal Report Center: 51
Services beginning 01/01/2010 ending 03/31/2010 Date of Report:05/17/2010 Page: 1
Eligibility Filter:Part C (excluding not eligible)
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 322 223.75 8278.75 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 347 423.25 15660.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 882 4167.75 154179.00 36.99
Subtotal (Total Children Is Unduplicated) 886 4814.75 178118.00 36.99
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Screening, Eval, and Assessment,Class #02
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.00 10.80 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.00 21.79 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.00 28.28 28.28
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.00 239.20 119.60
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 2 2.00 250.00 125.00
EVAL-EVAL-DEVELOPMENTAL EVALUATION 6 6.00 300.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 7 13.00 675.00 51.92
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 5.00 375.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 2.00 150.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.50 112.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 8 8.50 637.50 75.00
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 2 2.50 138.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 72 85.00 6300.00 74.12
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 34 35.00 2587.50 73.93
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 17 22.50 1650.00 73.33
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 17 98.00 1404.75 14.33
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 118 131.50 9637.50 73.29
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 15 15.00 607.50 40.50
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.00 48.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 21 21.00 1018.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 6 6.00 291.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 17 17.00 824.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 39 39.00 1891.50 48.50
VISF-VISF-VISION EVALUATION FUNCTIONAL 1 1.00 225.00 225.00
Subtotal (Total Children Is Unduplicated) 220 517.50 29425.07 56.86
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 19 49.00 17757.26 362.39
AUD-92630-AUD REHAB PRELING HEARING LOSS 2 5.00 344.30 68.86
AUD-92633-AUD REHAB POSTLING HEARING LOSS 1 1.00 68.86 68.86
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 18 17.25 862.50 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 7 8.50 425.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 6 2.75 68.75 25.00
CONPP-CONPP-CONSULT, PT, PHONE 6 3.75 93.75 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 2 1.00 31.25 31.25
CONSP-CONSP-CONSULT, SLP, PHONE 6 2.00 50.00 25.00
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 5 207.25 10362.50 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 63.50 3175.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 301 1879.25 93962.50 50.00
HERN-EIIF_NM-EI HEARING SERVICES AFTER SHINE NONMED 10 70.00 3500.00 50.00
INTR-INTR-INTERPRETER 2 5.00 85.00 17.00
OCCT-97530-OT SESSION BY LICENSED OT 122 561.50 37948.22 67.58
OCCT-97530HM-OT SESSION BY OT ASST 6 15.50 841.96 54.32
PHY-97110-PT SESSION BY LICENSED PT 118 648.75 43756.64 67.45
PHY-97110HM-PT SESSION BY PT ASST 23 121.75 6572.72 53.99
SENS-V5050-MED HEARING AID - ANALOG/DIGITAL 1 2.00 474.24 237.12
SENS-V5264-EARMOLD 1 2.00 37.44 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 260 1762.25 117347.20 66.59
SPL-92508-GROUP SPL SESSION PER CHILD 1 6.50 85.80 13.20
TRAN-TRAN-FAMILY TRANSPORTATION 1 672.00 136.29 0.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 488 106893 52173.50 0.49
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 1 1.50 75.00 50.00
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 3 26.25 1312.50 50.00
Subtotal (Total Children Is Unduplicated) 554 113028 391548.18 3.46
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Total 118360.50 599091.25 5.06
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Number of Children (Unduplicated) With at Least One Service 890
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Center 51
Flag Claims Units Chgs Paid
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R 19 20.00 740.00 0.00
U 0 0.00 0.00 0.00
B 3695 2663.75 99376.00 0.00
P 2519 109882.00 198116.31 198116.31
D 14 12.25 463.75 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
4788 5781.75 300367.44 0.00
Other 1 0.75 27.75 0.00
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Total 11036 118360.50 599091.25 198116.31