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:Program Patients
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 502 1580.25 58321.25 36.91
Subtotal (Total Children Is Unduplicated) 502 1580.25 58321.25 36.91
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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 5 9.00 675.00 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 24 53.50 4012.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 19 40.00 3000.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 20 39.50 2962.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 99 195.00 10822.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 81 181.50 13612.50 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) 173 614.50 39322.26 63.99
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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 304 1761.00 88050.00 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 6 19.00 950.00 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 39 207.50 14085.10 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) 350 2407.50 128405.02 53.34
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Total 4602.25 226048.53 49.12
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Number of Children (Unduplicated) With at Least One Service 577
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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 787 947.75 49151.53 48151.53
D 2 4.00 300.00 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
2299 2139.25 114911.79 200.00
Other 0 0.00 0.00 0.00
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Total 4808 4602.25 226048.53 48351.53