CMS/EIP Fiscal Report Center: 54
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 305 124.75 4615.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 205 210.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 608 804.75 29701.75 36.91
TCM-T1017TL-TARGETED CASE MANAGEMENT 1333 4852.00 178987.50 36.89
Subtotal (Total Children Is Unduplicated) 1344 5991.50 213305.00 35.60
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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) 1 1.00 8.83 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 4 4.00 43.20 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 3 3.00 65.37 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.00 28.28 28.28
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 1 1.00 125.00 125.00
EXIT-EXIT-TRANSITION ASSESSMENT 34 79.50 3975.00 50.00
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 1 1.50 83.25 55.50
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 22 38.00 2850.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 19 27.50 2062.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 24 41.50 3112.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 20 35.00 1942.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 31 52.50 3937.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 77 113.50 8512.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 110 187.50 10406.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 100 160.00 12000.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 3 3.00 145.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 26 26.00 1261.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 5 5.00 242.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 7 7.00 339.50 48.50
SENS-V5014TS-HEARING AID REPAIR IN-OFFICE 1 2.00 30.00 15.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 26 26.00 1261.00 48.50
Subtotal (Total Children Is Unduplicated) 352 816.50 52442.80 64.23
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 15 16.50 825.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 68 72.50 3625.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 5 3.25 81.25 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 24 22.75 1087.50 47.80
CONOP-CONOP-CONSULT, OT, PHONE 2 2.00 50.00 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 14 13.25 662.50 50.00
CONPP-CONPP-CONSULT, PT, PHONE 1 0.25 6.25 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 45 43.50 2150.00 49.43
CONSP-CONSP-CONSULT, SLP, PHONE 5 4.50 112.50 25.00
ECE-ECE-EARLY CHILDHOOD EDUCATION 2 191.20 2390.00 12.50
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 3 31.25 1562.50 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 303 2042.75 102112.50 49.99
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 8 18.00 900.00 50.00
INTR-INTR-INTERPRETER 43 229.00 11480.00 50.13
OCCT-97530-OT SESSION BY LICENSED OT 93 527.49 35670.94 67.62
OCCT-97530HM-OT SESSION BY OT ASST 20 108.75 5907.30 54.32
PHY-97110-PT SESSION BY LICENSED PT 43 250.60 16444.80 65.62
SENS-V5014-HEARING AID REPAIR BY MANUFACTURER 1 1.00 114.00 114.00
SENS-V5264-EARMOLD 1 1.00 18.72 18.72
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 7 7.00 350.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 143 934.57 62794.62 67.19
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 10 103.00 5594.96 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 1 0.50 6.60 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 840 209814 147257.15 0.70
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 3 18.00 900.00 50.00
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 4 7.00 350.00 50.00
Subtotal (Total Children Is Unduplicated) 901 214464 402454.09 1.88
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Total 221271.61 668201.89 3.02
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Number of Children (Unduplicated) With at Least One Service 1392
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Center 54
Flag Claims Units Chgs Paid
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R 32 35.50 1459.50 0.00
U 0 0.00 0.00 0.00
B 5055 3861.75 160989.46 0.00
P 3299 162726.73 301774.86 301706.98
D 31 18.00 793.27 0.00
S 2 0.75 27.75 0.00
H 0 0.00 0.00 0.00
T 1 0.25 9.25 0.00
5538 54627.38 203101.55 0.00
Other 2 1.25 46.25 0.00
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Total 13960 221271.61 668201.89 301706.98