CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 Page: 1
Agency Filter:EXT
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 3 1.75 64.75 37.00
Subtotal (Total Children Is Unduplicated) 3 1.75 64.75 37.00
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 6 10.00 438.00 43.80
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.00 8.83 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.00 21.60 10.80
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.00 8.44 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.00 43.58 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.00 56.56 28.28
EXIT-EXIT-TRANSITION ASSESSMENT 94 185.00 9250.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 7.00 525.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.00 111.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.00 75.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 5 11.00 610.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 8.50 637.50 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 5 5.00 242.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 3 3.00 145.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 6 8.00 388.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 24 37.00 1794.50 48.50
Subtotal (Total Children Is Unduplicated) 150 285.50 14356.51 50.29
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 10 37.00 4202.80 113.59
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 71 88.50 4425.00 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 3 0.75 18.75 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 6 3.50 175.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 4 2.75 68.75 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 2 1.75 87.50 50.00
CONOP-CONOP-CONSULT, OT, PHONE 1 0.25 6.25 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 2 1.75 87.50 50.00
CONPP-CONPP-CONSULT, PT, PHONE 2 1.00 25.00 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 28 26.00 1300.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 9 6.00 150.00 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 31 167.00 4725.00 28.29
EIIF-90847-FAMILY PSYCHOTHERAPY WITH PATIENT 1 5.00 306.35 61.27
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 15 75.50 3775.00 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 21 105.50 5275.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 651 4254.75 212476.28 49.94
INTR-INTR-INTERPRETER 75 449.50 14097.50 31.36
OCCT-97530-OT SESSION BY LICENSED OT 62 320.50 22889.95 71.42
OCCT-97530HM-OT SESSION BY OT ASST 3 3.50 190.12 54.32
PHY-97110-PT SESSION BY LICENSED PT 171 981.50 68541.96 69.83
PHY-97110HM-PT SESSION BY PT ASST 14 35.00 1901.20 54.32
RSPT-RSPT-RESPITE 1 77.50 620.00 8.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 481 2911.00 200096.55 68.74
SPL-92508-GROUP SPL SESSION PER CHILD 24 53.75 708.36 13.18
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1117 262120 130968.50 0.50
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 8 79.75 3987.50 50.00
Subtotal (Total Children Is Unduplicated) 1272 271809 681105.82 2.51
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Total 272096.25 695527.08 2.56
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Number of Children (Unduplicated) With at Least One Service 1286
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Center 01
Flag Claims Units Chgs Paid
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R 1 0.25 9.25 0.00
U 0 0.00 0.00 0.00
B 3 3.00 150.00 0.00
P 5912 154801.50 232518.87 232500.99
D 7 8.00 411.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 3561 98598.00 161107.32 161157.32
1873 7776.00 190622.08 3450.00
Other 1421 10909.50 110708.56 0.00
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Total 12778 272096.25 695527.08 397108.31