CMS/EIP Fiscal Report Center: 54
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 266 103.50 3829.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 150 156.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 438 558.75 20572.00 36.82
TCM-T1017TL-TARGETED CASE MANAGEMENT 1160 3588.50 132247.25 36.85
TCON-TCON-TRANSITION CONFERENCE 1 1.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1176 4407.75 156648.75 35.54
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 3 3.00 31.86 10.62
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 20 20.00 176.60 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 30 32.00 345.60 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 25 26.00 566.54 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 2 2.00 108.76 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 7 7.00 197.96 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 10 12.00 358.74 29.90
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.00 46.80 46.80
AUDE-V5090-DISPENSING FEE PER HEARING AID 2 2.00 239.20 119.60
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 2 3.00 375.00 125.00
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 0.50 25.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 13 34.50 1725.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 8 12.00 900.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 10 14.00 1050.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 1.50 112.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 23 30.50 2287.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 31 42.00 2331.00 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 2 4.00 222.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 31 55.00 4125.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 36 55.50 4162.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.50 112.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 66 103.50 5744.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 74 110.50 8287.50 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 6 6.00 291.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 14 14.00 679.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 3 3.00 145.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 8 8.00 388.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 44 46.00 2231.00 48.50
Subtotal (Total Children Is Unduplicated) 278 650.00 37266.31 57.33
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 4 3.50 175.00 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 1 0.50 12.50 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 54 49.00 2450.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 6 3.25 81.25 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 23 21.75 1087.50 50.00
CONOP-CONOP-CONSULT, OT, PHONE 2 1.50 37.50 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 3 2.25 112.50 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 57 50.25 2512.50 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 4 2.00 50.00 25.00
ECE-ECE-EARLY CHILDHOOD EDUCATION 1 54.40 680.00 12.50
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.00 25.00 25.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 21 150.00 7512.50 50.08
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 334 2222.50 111112.50 49.99
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 4 9.00 450.00 50.00
INTR-INTR-INTERPRETER 18 96.50 4825.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 148 837.86 56856.47 67.86
OCCT-97530HM-OT SESSION BY OT ASST 2 8.00 434.56 54.32
PHY-97110-PT SESSION BY LICENSED PT 83 434.50 29391.62 67.64
SENS-V5264-EARMOLD 1 1.00 18.72 18.72
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 3 3.00 150.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 255 1398.75 94947.15 67.88
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 8 26.50 1439.48 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 5 16.50 217.80 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 683 182539 128281.90 0.70
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 6 8.00 400.00 50.00
Subtotal (Total Children Is Unduplicated) 779 187941 443261.45 2.36
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Total 192998.26 637176.51 3.30
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Number of Children (Unduplicated) With at Least One Service 1224
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Center 54
Flag Claims Units Chgs Paid
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R 68 65.00 2854.50 0.00
U 0 0.00 0.00 0.00
B 1842 1443.75 60635.18 0.00
P 4755 142106.99 340481.85 340443.97
D 111 74.75 3198.98 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
4994 49307.77 230006.00 0.00
Other 0 0.00 0.00 0.00
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Total 11770 192998.26 637176.51 340443.97