CMS/EIP Fiscal Report Center: 53
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 97 36.75 1359.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 272 279.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 298 245.75 9092.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 521 1137.75 42096.75 37.00
TCON-TCON-TRANSITION CONFERENCE 28 29.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 526 1728.25 52549.25 30.41
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 2 2.00 97.00 48.50
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 2 2.00 21.24 10.62
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 36 39.00 344.37 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 30 34.00 367.20 10.80
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 3 3.00 25.32 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 39 44.00 958.76 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 3 3.00 163.14 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 5 5.00 141.40 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 28 30.00 954.30 31.81
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 6 6.00 650.00 108.33
EXIT-EXIT-TRANSITION ASSESSMENT 56 108.00 5400.00 50.00
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 4 7.50 416.25 55.50
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 7.00 525.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 7.50 562.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 12.00 666.00 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 113 209.00 15190.44 72.68
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 45 85.00 7300.48 85.89
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 30 58.00 4503.64 77.65
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 34 67.00 5141.14 76.73
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 156 295.50 20667.25 69.94
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 111 228.00 19913.94 87.34
NUTR-97802-NUTRITIONAL EVAL, INITIAL 1 1.50 75.00 50.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 11 11.00 533.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 3 3.00 145.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 15 15.00 727.50 48.50
SENS-V5014TS-HEARING AID REPAIR IN-OFFICE 1 1.00 15.00 15.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 39 40.00 1940.00 48.50
Subtotal (Total Children Is Unduplicated) 309 1324.00 87445.87 66.05
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.00 55.00 55.00
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 97 144.75 7237.50 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 21 16.75 418.75 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 14 13.00 650.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 2 0.75 18.75 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 5 5.00 250.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 1 0.25 6.25 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 7 10.00 500.00 50.00
CONPP-CONPP-CONSULT, PT, PHONE 2 1.50 37.50 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 6.00 300.00 50.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 12 23.00 575.00 25.00
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 30 188.00 9400.00 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 4 21.00 1050.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 342 2109.00 105450.00 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 9 18.00 900.00 50.00
INTR-INTR-INTERPRETER 10 25.00 1250.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 45 222.00 17205.00 77.50
OCCT-97530HM-OT SESSION BY OT ASST 1 3.00 162.96 54.32
PHY-97110-PT SESSION BY LICENSED PT 68 503.25 34161.40 67.88
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 8 10.00 500.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 69 382.50 25964.10 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 563 93903.0 46951.50 0.50
Subtotal (Total Children Is Unduplicated) 597 97606.8 253043.71 2.59
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Total 100659.00 393038.83 3.90
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Number of Children (Unduplicated) With at Least One Service 681
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Center 53
Flag Claims Units Chgs Paid
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R 53 97.00 5347.00 0.00
U 0 0.00 0.00 0.00
B 333 362.75 16650.75 0.00
P 792 859.75 43294.71 43294.46
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 649 19094.40 27805.99 27787.24
T 649 20255.00 28733.73 28733.73
6380 59989.10 271156.65 398.50
Other 1 1.00 50.00 0.00
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Total 8857 100659.00 393038.83 100213.93