CMS/EIP Fiscal Report Center: 51
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 343 238.25 8815.25 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 378 457.25 16918.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 388 1636.25 60532.00 36.99
Subtotal (Total Children Is Unduplicated) 734 2331.75 86265.50 37.00
----------------------------------------------------------------------------------------------------------------
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 3 3.00 225.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 2.00 150.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 5.00 375.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 32 33.00 2400.00 72.73
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 23 23.00 1725.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 3.50 225.00 64.29
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 12 88.50 900.00 10.17
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 56 59.50 4200.00 70.59
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 12 12.00 486.00 40.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 12 12.00 582.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 6 6.00 291.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 24 24.00 1164.00 48.50
VISF-VISF-VISION EVALUATION FUNCTIONAL 1 1.00 225.00 225.00
Subtotal (Total Children Is Unduplicated) 128 299.50 14521.57 48.49
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 17 38.00 7567.90 199.16
AUD-92630-AUD REHAB PRELING HEARING LOSS 1 2.00 137.72 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 98 632.25 31612.50 50.00
INTR-INTR-INTERPRETER 2 5.00 85.00 17.00
OCCT-97530-OT SESSION BY LICENSED OT 38 178.00 12048.00 67.69
PHY-97110-PT SESSION BY LICENSED PT 34 153.50 10139.07 66.05
PHY-97110HM-PT SESSION BY PT ASST 2 17.00 882.70 51.92
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 127 840.25 54693.96 65.09
TRAN-TRAN-FAMILY TRANSPORTATION 1 672.00 136.29 0.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 516 108378 52916.00 0.49
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 1 1.50 75.00 50.00
Subtotal (Total Children Is Unduplicated) 550 111228 185874.57 1.67
----------------------------------------------------------------------------------------------------------------
Total 113858.75 286661.64 2.52
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 841
----------------------------------------------------------------------------------------------------------------
Center 51
Flag Claims Units Chgs Paid
-------------------------------------------------
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 2554 111337.50 197254.22 197254.22
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
3534 2509.00 88943.67 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 6102 113858.75 286661.64 197254.22