CMS/EIP Fiscal Report Center: 07
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 1230 969.50 35871.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 203 208.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 756 1071.25 39562.25 36.93
TCM-T1017TL-TARGETED CASE MANAGEMENT 1760 5747.00 212583.50 36.99
TCON-TCON-TRANSITION CONFERENCE 39 39.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1839 8034.75 288017.25 35.85
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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) 6 7.00 56.81 8.12
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 8 9.00 96.78 10.75
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 7 8.00 169.53 21.19
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 3 3.00 163.14 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.00 27.19 27.19
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 4 5.00 159.05 31.81
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.00 46.80 46.80
AUDE-V5090-DISPENSING FEE PER HEARING AID 2 3.00 331.60 110.53
EXIT-EXIT-TRANSITION ASSESSMENT 34 60.25 3012.50 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 6.00 450.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 6 14.00 1050.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 7.00 388.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 45 83.50 6137.85 73.51
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 11 21.50 1612.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 11 14.00 911.61 65.12
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 174 333.50 18509.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 254 681.00 51000.00 74.89
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 4 4.00 291.12 72.78
NUTR-97802-NUTRITIONAL EVAL, INITIAL 4 3.75 187.50 50.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.00 48.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 26 26.00 1209.36 46.51
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 14 14.00 566.50 40.46
SCREEN-T1023-INTERDISCIPLINARY SCREENING 52 52.00 2600.00 50.00
SENS-V5014TS-HEARING AID REPAIR IN-OFFICE 2 5.00 75.00 15.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 90 91.00 4413.50 48.50
Subtotal (Total Children Is Unduplicated) 490 1456.50 93573.71 64.25
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 2.00 394.31 197.16
AUD-92630-AUD REHAB PRELING HEARING LOSS 1 3.00 0.99 0.33
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 21 20.50 1025.00 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 2 1.00 25.00 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 26 23.75 1187.50 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 9 3.25 81.25 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 21 26.00 1300.00 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 18 20.50 1025.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 36 36.00 1800.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 2 1.75 43.75 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 632 4547.25 227362.50 50.00
INTR-INTR-INTERPRETER 6 25.75 1287.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 118 795.00 50873.24 63.99
OCCT-97530HM-OT SESSION BY OT ASST 1 3.50 190.12 54.32
PHY-97110-PT SESSION BY LICENSED PT 85 461.00 28795.97 62.46
PHY-97110HM-PT SESSION BY PT ASST 1 9.25 502.46 54.32
SENS-V5014-HEARING AID REPAIR BY MANUFACTURER 1 2.00 30.00 15.00
SENS-V5050-MED HEARING AID - ANALOG/DIGITAL 2 3.00 711.36 237.12
SENS-V5264-EARMOLD 5 7.00 131.04 18.72
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 2 2.00 100.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 362 2676.17 172858.16 64.59
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 734 138079 69022.00 0.50
Subtotal (Total Children Is Unduplicated) 1077 146749 558747.15 3.81
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Total 156239.92 940338.11 6.02
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Number of Children (Unduplicated) With at Least One Service 1917
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Center 07
Flag Claims Units Chgs Paid
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R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 11 8.00 296.00 0.00
P 8784 140742.42 500560.33 500560.33
D 0 0.00 0.00 0.00
S 304 151.50 5596.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
10998 15337.00 433848.53 0.00
Other 2 1.00 37.00 0.00
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Total 20099 156239.92 940338.11 500560.33