CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2010 ending 09/30/2010 Date of Report:11/17/2010 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 195 95.500000 3533.5000 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 348 410.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 423 827.750000 30626.7500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 714 2172.250000 80151.2500 36.8978
TCON-TCON-TRANSITION CONFERENCE 41 43.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 730 3548.500000 114311.5000 32.2140
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 2 2.000000 97.0000 48.5000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.000000 12.3300 12.3300
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 5 6.000000 52.3200 8.7200
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 5 5.000000 54.0000 10.8000
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 5 6.000000 131.0000 21.8333
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.000000 53.8300 53.8300
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 2 2.000000 63.0400 31.5200
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 14 15.000000 1625.0000 108.3333
EXIT-EXIT-TRANSITION ASSESSMENT 62 182.750000 9137.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 16 37.000000 2775.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 8 14.500000 1087.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 24 49.000000 2683.5000 54.7653
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 27 50.499990 2802.7494 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 56 118.999996 9609.9598 80.7560
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 33 64.999890 4995.6518 76.8563
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 176 394.999911 23144.2750 58.5931
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 145 429.000000 32944.6200 76.7940
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 17 17.210510 834.7097 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 26 27.000000 1309.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 31 33.000000 2333.0800 70.6994
Subtotal (Total Children Is Unduplicated) 335 1456.960297 95746.5657 65.7167
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 5 24.000000 3653.1000 152.2125
AUD-92630-AUD REHAB PRELING HEARING LOSS 1 2.000000 143.2200 71.6100
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 100 263.500000 13175.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 29 98.000000 2450.0000 25.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 3 8.500000 425.0000 50.0000
CONIP-CONIP-CONSULT, ITDS, PHONE 1 1.000000 25.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 1.000000 25.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 7 14.000000 700.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 2 1.500000 37.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 8 8.000000 400.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 2 1.500000 37.5000 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 1 9.000000 660.7800 73.4200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 22 47.000000 1175.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 29 114.000000 5700.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 392 2535.250000 126664.5000 49.9613
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 7 37.000000 1850.0000 50.0000
INTR-INTR-INTERPRETER 11 15.000000 750.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 47 234.750000 15934.8300 67.8800
PHY-97110-PT SESSION BY LICENSED PT 68 502.250000 34092.7300 67.8800
RSPT-RSPT-RESPITE 1 40.000000 0.0000 0.0000
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 3 4.000000 200.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 97 554.500000 37639.4600 67.8800
SPL-92508-GROUP SPL SESSION PER CHILD 4 13.750000 181.5000 13.2000
TRAN-TRAN-FAMILY TRANSPORTATION 1 20.000000 2000.0000 100.0000
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 615 130481.0000 65190.0000 0.4996
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 2 9.000000 450.0000 50.0000
Subtotal (Total Children Is Unduplicated) 643 135040.5000 313610.1200 2.3223
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Total 140045.960297 523668.1857 3.7393
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Number of Children (Unduplicated) With at Least One Service 862
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Center 53
Flag Claims Units Chgs Paid
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R 97 107.500000 4255.5000 311.0000
U 0 0.000000 0.0000 0.0000
B 1346 1296.000000 54015.7500 0.0000
P 712 852.053285 42945.2159 41295.2200
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1443 45387.716930 72846.1396 72829.0200
T 1625 33169.000000 62389.4900 62389.4900
6005 59198.690082 286979.0902 37.5000
Other 5 35.000000 237.0000 0.0000
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Total 11233 140045.960297 523668.1857 176862.2300