CMS/EIP Fiscal Report Center: 03
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 1 0.25 9.25 37.00
TCON-TCON-TRANSITION CONFERENCE 1 1.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1 1.25 9.25 7.40
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Screening, Eval, and Assessment,Class #02
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 1.00 115.00 115.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.00 300.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 25 50.00 3750.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 10 10.00 365.69 36.57
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 13 13.00 630.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 8 8.00 388.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 17 17.00 798.34 46.96
SPCH-92506-SPEECH EVAL BY LICENSED SLP 34 34.00 1605.48 47.22
Subtotal (Total Children Is Unduplicated) 96 137.00 7953.01 58.05
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 3 3.00 963.15 321.05
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 150 204.00 8975.00 44.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 2 2.00 31.25 15.63
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 74 169.25 5987.50 35.38
CONIP-CONIP-CONSULT, ITDS, PHONE 10 5.75 125.00 21.74
CONOF-CONOF-CONSULT, OT, FACE TO FACE 37 61.75 3087.50 50.00
CONOP-CONOP-CONSULT, OT, PHONE 3 1.25 31.25 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 24 41.75 2050.00 49.10
CONPP-CONPP-CONSULT, PT, PHONE 2 1.25 31.25 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 87 135.25 6762.50 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 1 0.50 12.50 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 175 1253.25 61922.50 49.41
INTR-INTR-INTERPRETER 13 181.00 9552.50 52.78
OCCT-97530-OT SESSION BY LICENSED OT 70 480.00 28145.40 58.64
PHY-97110-PT SESSION BY LICENSED PT 67 419.25 26650.54 63.57
SENS-V5050-MED HEARING AID - ANALOG/DIGITAL 1 2.00 798.00 399.00
SENS-V5264-EARMOLD 2 4.00 72.00 18.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 142 991.00 60274.63 60.82
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 2.00 12.94 6.47
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 479 97577.0 48772.10 0.50
Subtotal (Total Children Is Unduplicated) 551 101535 264257.51 2.60
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Total 101673.50 272219.77 2.68
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Number of Children (Unduplicated) With at Least One Service 569
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Center 03
Flag Claims Units Chgs Paid
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R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 2301 33975.25 88592.05 88592.05
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
4684 67698.25 183627.72 0.00
Other 0 0.00 0.00 0.00
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Total 6985 101673.50 272219.77 88592.05