CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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 929 460.25 17029.25 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 894 1040.50 38498.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 2611 7735.75 285862.00 36.95
Subtotal (Total Children Is Unduplicated) 2636 9236.50 341389.75 36.96
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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 97 193.00 9650.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 11 20.00 1500.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.50 112.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 9 18.50 1387.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 8 14.50 804.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 118 201.00 15075.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 20 35.50 2662.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 21 34.50 2587.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 101 195.50 10850.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 77 131.00 9825.00 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) 335 916.00 57602.51 62.88
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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 78 108.00 5400.00 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 3 0.75 18.75 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 8 5.25 262.50 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 16 82.50 4125.00 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 23 110.50 5525.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 664 4344.75 216976.28 49.94
INTR-INTR-INTERPRETER 86 464.75 14585.00 31.38
OCCT-97530-OT SESSION BY LICENSED OT 63 328.50 23432.99 71.33
OCCT-97530HM-OT SESSION BY OT ASST 3 3.50 190.12 54.32
PHY-97110-PT SESSION BY LICENSED PT 172 994.50 69424.40 69.81
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 483 2918.75 200622.62 68.74
SPL-92508-GROUP SPL SESSION PER CHILD 24 53.75 708.36 13.18
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1157 267000 133408.50 0.50
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 8 79.75 3987.50 50.00
Subtotal (Total Children Is Unduplicated) 1316 276856 692147.37 2.50
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Total 287008.75 1091139.63 3.80
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Number of Children (Unduplicated) With at Least One Service 2737
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Center 01
Flag Claims Units Chgs Paid
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R 270 181.50 7041.50 0.00
U 0 0.00 0.00 0.00
B 3664 2688.50 101272.75 0.00
P 6000 157198.50 235405.85 235295.47
D 274 409.75 27298.25 0.00
S 2537 1913.50 70660.75 0.00
H 4 7.00 525.00 0.00
T 3604 99998.50 162500.02 162550.02
9530 13032.25 367668.04 3500.00
Other 1503 11579.25 118767.47 0.00
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Total 27386 287008.75 1091139.63 401345.49