CMS/EIP Fiscal Report Center: 53
Services beginning 01/01/2010 ending 03/31/2010 Date of Report:05/17/2010 Page: 1
Payclass Filters:MED
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
TCM-T1017TL-TARGETED CASE MANAGEMENT 296 669.00 24753.00 37.00
Subtotal (Total Children Is Unduplicated) 296 669.00 24753.00 37.00
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.00 10.62 10.62
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 16 16.00 141.28 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 13 13.00 140.40 10.80
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.00 8.44 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 16 16.00 348.64 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.00 54.38 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 3.00 84.84 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 12 12.00 381.72 31.81
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.00 300.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 5.00 375.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 7.50 416.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 33 62.50 4687.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 19 37.00 2775.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 22 43.00 3225.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 108 206.50 11460.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 75 152.50 11437.50 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 5 5.00 242.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 3 3.00 145.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 7 7.00 339.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 14 14.00 679.00 48.50
Subtotal (Total Children Is Unduplicated) 163 610.00 37253.82 61.07
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 4 9.00 225.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 257 1555.00 77750.00 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 6 15.00 750.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 19 70.50 4785.54 67.88
OCCT-97530HM-OT SESSION BY OT ASST 1 3.00 162.96 54.32
PHY-97110-PT SESSION BY LICENSED PT 36 244.00 16562.72 67.88
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 7 9.00 450.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 21 90.50 6143.14 67.88
Subtotal (Total Children Is Unduplicated) 293 1996.00 106829.36 53.52
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Total 3275.00 168836.18 51.55
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Number of Children (Unduplicated) With at Least One Service 447
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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 782 852.00 42788.17 42787.92
D 0 0.00 0.00 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
2117 1962.25 104000.26 398.50
Other 1 1.00 50.00 0.00
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Total 3286 3275.00 168836.18 43186.42