CMS/EIP Fiscal Report Center: 05
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
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 3 3.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 3 3.00 0.00 0.00
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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 7 7.00 388.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 19 34.00 2175.00 63.97
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 13 17.00 1200.00 70.59
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 37 62.00 3441.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 8.50 637.50 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 4.00 194.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.00 97.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 5 5.00 242.50 48.50
Subtotal (Total Children Is Unduplicated) 105 201.00 11532.31 57.37
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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 277 385.00 19250.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 16 6.50 162.50 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 47 23.50 1175.00 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 83 43.00 2150.00 50.00
CONPP-CONPP-CONSULT, PT, PHONE 1 0.50 12.50 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 151 162.00 8100.00 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 15 60.50 1467.38 24.25
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 87 414.25 18317.82 44.22
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 221 1229.25 60658.18 49.35
INTR-INTR-INTERPRETER 6 37.50 1875.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 46 146.25 7891.05 53.96
PHY-97110-PT SESSION BY LICENSED PT 81 349.54 18239.04 52.18
PHY-97110HM-PT SESSION BY PT ASST 3 5.00 271.60 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 120 406.95 24661.34 60.60
SPL-92508-GROUP SPL SESSION PER CHILD 7 11.03 152.75 13.85
TRAN-TRAN-FAMILY TRANSPORTATION 2 12.00 170.58 14.22
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 428 98110.0 49055.00 0.50
Subtotal (Total Children Is Unduplicated) 490 101484 216731.95 2.14
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Total 101687.77 228264.26 2.24
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Number of Children (Unduplicated) With at Least One Service 503
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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 1555 40581.27 67937.05 67937.05
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
3500 61106.50 160327.21 0.00
Other 0 0.00 0.00 0.00
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Total 5055 101687.77 228264.26 67937.05