CMS/EIP Fiscal Report Center: 05
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 Page: 1
Payclass Filters:GR
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
CASE-CASE-NON-TCM CASE MANAGEMENT 209 100.00 3700.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 295 352.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 345 314.00 11618.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 349 1283.00 47471.00 37.00
Subtotal (Total Children Is Unduplicated) 582 2049.00 62789.00 30.64
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Screening, Eval, and Assessment,Class #02
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.00 31.81 31.81
EXIT-EXIT-TRANSITION ASSESSMENT 31 56.50 2825.00 50.00
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 5 5.50 305.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 12 19.16 1249.76 65.23
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 4.00 300.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 4.50 281.69 62.60
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 27 45.00 2497.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 12.00 900.00 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 3.00 145.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.00 97.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 83 153.66 8682.01 56.50
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 46 48.25 2412.50 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 281 391.75 19587.50 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 17 6.75 168.75 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 47 23.50 1175.00 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 96 52.00 2600.00 50.00
CONPP-CONPP-CONSULT, PT, PHONE 1 0.50 12.50 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 151 159.50 7975.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 6 1.75 43.75 25.00
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 11 31.00 665.96 21.48
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 11 43.00 1029.88 23.95
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 63 247.75 9992.82 40.33
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 161 894.75 43933.18 49.10
INTR-INTR-INTERPRETER 6 37.50 1875.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 13 31.45 1729.18 54.98
PHY-97110-PT SESSION BY LICENSED PT 23 90.02 3985.04 44.27
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 55 203.46 12018.64 59.07
TRAN-TRAN-FAMILY TRANSPORTATION 2 12.00 170.58 14.22
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 432 98875.0 49437.50 0.50
Subtotal (Total Children Is Unduplicated) 477 101150 158812.78 1.57
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Total 103352.59 230283.79 2.23
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Number of Children (Unduplicated) With at Least One Service 647
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Center 05
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 1501 40462.27 62063.55 62063.55
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
5784 62890.32 168220.24 0.00
Other 0 0.00 0.00 0.00
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Total 7285 103352.59 230283.79 62063.55