CMS/EIP Fiscal Report Center: 54
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 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 492 1804.00 66646.25 36.94
Subtotal (Total Children Is Unduplicated) 991 2943.50 100963.75 34.30
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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 24 58.25 2912.50 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 14 27.50 2062.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 6.00 450.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.00 300.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 10 18.50 1026.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 20 33.50 2512.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 16 25.00 1875.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 44 76.00 4218.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 11 19.00 1425.00 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 12 12.00 582.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 4 3.19 154.34 48.38
PSTH-97001-EVAL BY LICENSED PT, INITIAL 6 6.00 291.00 48.50
SENS-V5014TS-HEARING AID REPAIR IN-OFFICE 1 2.00 30.00 15.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 19 19.00 921.50 48.50
Subtotal (Total Children Is Unduplicated) 150 325.44 19271.14 59.22
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 10 10.50 525.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 57 60.00 3000.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 3 2.25 56.25 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 24 22.75 1087.50 47.80
CONOP-CONOP-CONSULT, OT, PHONE 1 1.00 25.00 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 13 12.00 600.00 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 98 930.25 46512.50 50.00
INTR-INTR-INTERPRETER 43 227.00 11380.00 50.13
OCCT-97530-OT SESSION BY LICENSED OT 86 436.79 29500.08 67.54
OCCT-97530HM-OT SESSION BY OT ASST 20 108.55 5896.30 54.32
PHY-97110-PT SESSION BY LICENSED PT 43 228.13 14910.41 65.36
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 1 1.00 50.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 98 610.12 40748.50 66.79
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 10 102.25 5554.22 54.32
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 839 209628 147126.95 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) 897 212678 314576.68 1.48
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Total 215947.23 434811.57 2.01
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Number of Children (Unduplicated) With at Least One Service 1225
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Center 54
Flag Claims Units Chgs Paid
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R 29 31.00 1147.00 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 3046 162526.73 291356.82 291356.82
D 1 0.50 18.50 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
4759 53389.00 142289.25 0.00
Other 0 0.00 0.00 0.00
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Total 7835 215947.23 434811.57 291356.82