CMS/EIP Fiscal Report Center: 06
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 Page: 1
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 395 212.25 7853.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 620 643.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 395 367.50 13597.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1679 5140.50 190198.50 37.00
TCON-TCON-TRANSITION CONFERENCE 152 152.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1688 6515.25 211649.25 32.49
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 1.00 48.50 48.50
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 98 99.00 874.17 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 95 96.00 1036.80 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 93 94.00 2048.26 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 3.00 84.84 28.28
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 5.00 375.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 7.50 562.50 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 191 276.00 20700.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 177 251.00 18775.08 74.80
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 7 12.50 693.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 14 25.00 1875.00 75.00
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 2 2.00 54.44 27.22
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 25 25.00 1431.75 57.27
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 4 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 2 2.00 97.00 48.50
Subtotal (Total Children Is Unduplicated) 323 905.00 48948.09 54.09
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 3 3.00 840.04 280.01
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 13 9.50 475.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 0.50 25.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 1 0.50 12.50 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 11 16.50 825.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 3 1.00 25.00 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 6 5.75 287.50 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 5 4.50 225.00 50.00
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 5 38.00 1900.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 271 1768.25 84700.00 47.90
INTR-INTR-INTERPRETER 24 84.00 4785.00 56.96
OCCT-97530-OT SESSION BY LICENSED OT 112 567.00 37761.12 66.60
OCCT-97530HM-OT SESSION BY OT ASST 7 13.00 706.16 54.32
PHY-97110-PT SESSION BY LICENSED PT 196 1012.75 66591.43 65.75
PHY-97110HM-PT SESSION BY PT ASST 7 24.50 1302.44 53.16
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 604 3688.50 233134.20 63.21
SPL-92508-GROUP SPL SESSION PER CHILD 8 12.50 164.12 13.13
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 725 136689 68343.50 0.50
Subtotal (Total Children Is Unduplicated) 930 143939 502103.01 3.49
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Total 151359.00 762700.35 5.04
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Number of Children (Unduplicated) With at Least One Service 1740
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Center 06
Flag Claims Units Chgs Paid
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R 25 14.75 545.75 0.00
U 0 0.00 0.00 0.00
B 165 105.00 3885.00 434.75
P 8054 63184.75 202195.95 202228.07
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
17786 88054.50 556073.65 1213.44
Other 0 0.00 0.00 0.00
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Total 26030 151359.00 762700.35 203876.26