CMS/EIP Fiscal Report Center: 01
Services beginning 04/01/2010 ending 06/30/2010 Date of Report:08/18/2010 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 1195 546.50 20195.00 36.95
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 888 922.75 34141.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 2865 8643.75 319402.50 36.95
Subtotal (Total Children Is Unduplicated) 2907 10113.0 373739.25 36.96
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 4 4.00 194.00 48.50
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 2.00 17.66 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 4 5.00 61.92 12.38
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 3 3.00 68.62 22.87
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 2.00 108.76 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.00 56.56 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 2.00 58.91 29.46
EXIT-EXIT-TRANSITION ASSESSMENT 138 286.50 14325.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 52 76.00 5700.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 5.00 375.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 4.00 300.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 35 55.50 4162.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 28 39.50 2192.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 428 608.50 45600.00 74.94
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 46 64.50 4837.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 88 119.50 8962.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 355 493.50 27388.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 179 256.50 19200.00 74.85
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 3 3.00 145.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 5 5.00 242.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 4 5.00 242.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 13 15.00 699.21 46.61
SPCH-92506-SPEECH EVAL BY LICENSED SLP 27 27.00 1386.37 51.35
Subtotal (Total Children Is Unduplicated) 781 2084.00 136326.01 65.42
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 15 67.00 20261.03 302.40
AUD-HA_FUP-AUDIOLOGY SERVICES 1 1.00 50.00 50.00
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 104 141.00 7050.00 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 6 2.50 62.50 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 18 19.75 987.50 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 12 5.50 137.50 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 3 4.00 200.00 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 9 6.25 312.50 50.00
CONPP-CONPP-CONSULT, PT, PHONE 3 1.25 31.25 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 25 28.50 1425.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 8 7.25 181.25 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 39 270.50 7722.50 28.55
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 45 364.25 18212.50 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 10 38.25 1912.50 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 747 5294.00 262345.00 49.56
INTR-INTR-INTERPRETER 112 482.75 15182.78 31.45
OCCT-97530-OT SESSION BY LICENSED OT 64 392.00 28039.13 71.53
OCCT-97530HM-OT SESSION BY OT ASST 1 3.00 162.96 54.32
PHY-97110-PT SESSION BY LICENSED PT 199 1298.25 90915.75 70.03
PHY-97110HM-PT SESSION BY PT ASST 2 3.00 162.96 54.32
RSPT-RSPT-RESPITE 1 78.00 624.00 8.00
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 14 73.00 3650.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 405 2827.00 193966.91 68.61
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 2 7.50 407.40 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 4 10.00 132.00 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1253 301837 150916.00 0.50
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 6 42.25 2112.50 50.00
Subtotal (Total Children Is Unduplicated) 1408 313305 807163.42 2.58
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Total 325501.75 1317228.68 4.05
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Number of Children (Unduplicated) With at Least One Service 2982
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Center 01
Flag Claims Units Chgs Paid
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R 16 8.25 374.13 0.00
U 0 0.00 0.00 0.00
B 5437 3823.75 153010.00 9.25
P 5619 86445.75 173393.05 172332.71
D 261 294.00 16142.63 0.00
S 1069 853.00 37162.75 0.00
H 4453 101552.75 141301.45 139863.95
T 4976 103643.25 198947.12 198947.12
9597 10358.25 382047.59 1337.58
Other 3311 18522.75 214849.96 132.07
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Total 34739 325501.75 1317228.68 512622.68