CMS/EIP Fiscal Report Center: 55
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 194 92.50 3413.25 36.90
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 261 336.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 82 59.50 2201.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 593 1705.75 62446.75 36.61
TCON-TCON-TRANSITION CONFERENCE 35 35.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 601 2228.75 68061.50 30.54
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.00 8.83 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.00 10.80 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.00 21.79 21.79
EVAL-EVAL-DEVELOPMENTAL EVALUATION 3 9.50 475.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 5 6.75 387.50 57.41
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.50 112.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.50 112.50 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 63 104.50 7837.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 33 57.00 4275.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 11.50 862.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 37 68.00 3774.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 49 73.00 5612.50 76.88
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 3 3.00 145.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 9 9.00 455.88 50.65
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 6 6.00 291.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 35 35.00 1697.50 48.50
Subtotal (Total Children Is Unduplicated) 150 390.25 26128.80 66.95
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 5 5.00 2432.55 486.51
AUD-HA_FUP-AUDIOLOGY SERVICES 1 1.00 50.00 50.00
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 2 1.00 50.00 50.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 2 2.50 125.00 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 2 1.00 50.00 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 6.00 300.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 64 396.75 19837.50 50.00
INTR-INTR-INTERPRETER 1 16.00 708.00 44.25
OCCT-97530-OT SESSION BY LICENSED OT 86 452.50 30715.70 67.88
OCCT-97530HM-OT SESSION BY OT ASST 16 108.00 5866.56 54.32
PHY-97110-PT SESSION BY LICENSED PT 62 220.33 14924.51 67.74
PHY-97110HM-PT SESSION BY PT ASST 18 64.03 3479.34 54.34
SENS-V5264-EARMOLD 1 2.00 37.44 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 299 1566.00 106283.11 67.87
SPL-92508-GROUP SPL SESSION PER CHILD 1 2.00 26.40 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 362 67987.0 51898.09 0.76
Subtotal (Total Children Is Unduplicated) 421 70831.1 236784.20 3.34
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Total 73450.11 330974.50 4.51
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Number of Children (Unduplicated) With at Least One Service 691
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Center 55
Flag Claims Units Chgs Paid
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R 20 22.25 824.75 0.00
U 0 0.00 0.00 0.00
B 247 207.25 7437.00 0.00
P 3337 39234.35 100948.86 100939.61
D 34 34.25 1410.00 0.00
S 2 2.50 92.50 0.00
H 1 1.50 250.00 0.00
T 963 15636.10 28611.26 28611.26
5272 18311.91 191400.13 0.00
Other 0 0.00 0.00 0.00
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Total 9876 73450.11 330974.50 129550.87