CMS/EIP Fiscal Report Center: 53
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 248 182.00 6734.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 412 491.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 495 747.00 27639.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 796 2580.25 95284.25 36.93
TCON-TCON-TRANSITION CONFERENCE 116 117.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 820 4117.25 129657.25 31.49
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 3 3.00 145.50 48.50
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 2 2.00 21.24 10.62
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.00 16.30 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 16 18.00 158.94 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 9 13.00 140.40 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 16 19.00 414.01 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 4 6.00 326.28 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.00 28.28 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 14 17.00 540.77 31.81
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 6 6.00 625.00 104.17
EXIT-EXIT-TRANSITION ASSESSMENT 73 139.75 6987.50 50.00
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 4 7.00 388.50 55.50
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 9 18.00 1350.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 4.00 300.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 6 11.00 825.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 13 24.00 1332.00 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 78 161.50 9273.53 57.42
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 42 91.50 7210.92 78.81
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 29 62.00 5230.70 84.37
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 32 62.50 4803.64 76.86
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 161 322.00 19267.26 59.84
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 141 400.50 30850.48 77.03
NUTR-NUTR-UNSPECIFIED NUTRITIONAL EVAL 2 3.00 150.00 50.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 14 14.00 679.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 22 23.00 1115.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 34 35.00 1697.50 48.50
Subtotal (Total Children Is Unduplicated) 355 1464.75 93878.25 64.09
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.00 1337.50 1337.50
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 148 214.00 10700.00 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 31 32.50 812.50 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 5 7.50 375.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 1 0.25 6.25 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 1.00 50.00 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 17 22.75 1137.50 50.00
CONPP-CONPP-CONSULT, PT, PHONE 1 1.00 25.00 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 13 25.00 1250.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 2 101.00 2525.00 25.00
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 1 1.00 73.42 73.42
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 18 20.00 500.00 25.00
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 30 192.00 9600.00 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 4 19.00 950.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 413 2397.00 119850.00 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 8 27.00 1350.00 50.00
INTR-INTR-INTERPRETER 7 8.00 400.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 59 258.00 17989.68 69.73
OCCT-97530HM-OT SESSION BY OT ASST 10 25.00 1358.00 54.32
PHY-97110-PT SESSION BY LICENSED PT 74 469.75 31886.63 67.88
PHY-97110HM-PT SESSION BY PT ASST 10 31.50 1711.08 54.32
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 12 101.00 5050.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 93 484.25 32870.89 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 1 4.50 59.40 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 644 122297 61109.50 0.50
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 1 3.00 150.00 50.00
Subtotal (Total Children Is Unduplicated) 687 126744 303127.35 2.39
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Total 132326.00 526662.85 3.98
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Number of Children (Unduplicated) With at Least One Service 898
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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 1712 1504.00 61416.96 0.00
P 1883 33558.25 98410.55 97410.55
D 6 11.00 635.00 185.00
S 0 0.00 0.00 0.00
H 694 22441.75 31400.99 31400.99
T 1 0.75 27.75 0.00
8300 74803.75 334531.10 213.20
Other 0 0.00 0.00 0.00
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Total 12603 132326.00 526662.85 129209.74