CMS/EIP Fiscal Report Center: 53
Services beginning 04/01/2010 ending 06/30/2010 Date of Report:08/18/2010 Page: 1
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
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 449 1416.50 52410.50 37.00
Subtotal (Total Children Is Unduplicated) 449 1416.50 52410.50 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-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.00 16.30 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 7 7.00 61.81 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 4 5.00 54.00 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 8 8.00 174.32 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 2.00 108.76 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.00 28.28 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 6 7.00 222.67 31.81
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 7.00 525.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 3.00 225.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 6 10.00 750.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 10 16.00 888.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 16 37.50 2812.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 15 32.00 2400.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 18 36.00 2700.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 79 155.50 8630.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 62 133.50 10012.50 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 7 7.00 339.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 14 14.00 679.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 13 14.00 679.00 48.50
Subtotal (Total Children Is Unduplicated) 142 497.50 31317.51 62.95
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EI Services,Class #03
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 1 1.00 73.42 73.42
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 14 16.00 400.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 299 1742.00 87100.00 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 5 11.00 550.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 30 104.50 7052.78 67.49
OCCT-97530HM-OT SESSION BY OT ASST 8 20.00 1086.40 54.32
PHY-97110-PT SESSION BY LICENSED PT 38 206.75 14034.19 67.88
PHY-97110HM-PT SESSION BY PT ASST 10 31.50 1711.08 54.32
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 11 96.00 4800.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 37 148.00 10046.24 67.88
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 1 3.00 150.00 50.00
Subtotal (Total Children Is Unduplicated) 343 2379.75 127004.11 53.37
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Total 4293.75 210732.12 49.08
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Number of Children (Unduplicated) With at Least One Service 518
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Center 53
Flag Claims Units Chgs Paid
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R 7 6.50 240.50 0.00
U 0 0.00 0.00 0.00
B 1584 1370.75 56004.71 0.00
P 707 823.50 42006.53 41119.03
D 1 2.00 150.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 1 0.75 27.75 0.00
2254 2090.25 112302.63 200.00
Other 0 0.00 0.00 0.00
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Total 4554 4293.75 210732.12 41319.03