CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2010 ending 09/30/2010 Date of Report:11/17/2010 Page: 1
Payclass Filters:GR
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 423 797.250000 29498.2500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 271 664.750000 24549.5000 36.9304
TCON-TCON-TRANSITION CONFERENCE 41 43.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 602 2010.500000 57581.2500 28.6403
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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) 3 4.000000 34.8800 8.7200
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 5 5.000000 54.0000 10.8000
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 3 4.000000 87.2900 21.8225
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.000000 53.8300 53.8300
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 31.5200 31.5200
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 14 14.000000 1500.0000 107.1429
EXIT-EXIT-TRANSITION ASSESSMENT 62 182.750000 9137.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 19.000000 1425.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 9 20.500000 1137.7500 55.5000
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 27 49.301800 2736.2499 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 23 41.970930 3108.8198 74.0708
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 14.138730 1060.4048 75.0002
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 61 114.427309 6350.7156 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 42 132.107733 9908.0800 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 8 8.000000 388.0000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 4 4.000000 194.0000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 6 6.000000 291.0000 48.5000
Subtotal (Total Children Is Unduplicated) 182 628.196502 37908.3701 60.3448
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 5 23.000000 3603.4800 156.6730
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 7 7.000000 350.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 2 1.500000 37.5000 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 5 9.000000 225.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 29 114.000000 5700.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 125 658.000000 32900.0000 50.0000
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 3 15.000000 750.0000 50.0000
INTR-INTR-INTERPRETER 11 15.000000 750.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 21 95.250000 6465.5700 67.8800
PHY-97110-PT SESSION BY LICENSED PT 19 112.000000 7602.5600 67.8800
RSPT-RSPT-RESPITE 1 40.000000 0.0000 0.0000
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 2 3.000000 150.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 44 258.250000 17530.0100 67.8800
SPL-92508-GROUP SPL SESSION PER CHILD 1 8.000000 105.6000 13.2000
TRAN-TRAN-FAMILY TRANSPORTATION 1 20.000000 2000.0000 100.0000
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 615 130407.0000 65153.0000 0.4996
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 1 8.000000 400.0000 50.0000
Subtotal (Total Children Is Unduplicated) 626 132184.5000 160753.4400 1.2161
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Total 134823.196502 256243.0601 1.9006
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Number of Children (Unduplicated) With at Least One Service 792
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Center 53
Flag Claims Units Chgs Paid
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R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 3 6.000000 333.0000 333.0000
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
3007 56260.229572 120665.1805 37.5000
Other 1 0.250000 9.2500 0.0000
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Total 6079 134823.196502 256243.0601 135589.0100