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:Program Patients
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 202 96.25 3552.00 36.90
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 281 361.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 88 62.25 2303.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 631 1868.50 68376.00 36.59
TCON-TCON-TRANSITION CONFERENCE 35 35.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 639 2423.00 74231.25 30.64
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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 2 3.00 225.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.50 112.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.50 83.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 76 127.00 9525.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 46 80.00 6000.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 11 16.00 1200.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 47 85.50 4745.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 58 86.50 6625.00 76.59
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) 175 474.25 32058.30 67.60
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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 73728.36 343073.75 4.65
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Number of Children (Unduplicated) With at Least One Service 729
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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 272 229.25 8251.00 0.00
P 3409 39317.82 104748.59 104739.34
D 42 44.25 1837.00 0.00
S 2 2.50 92.50 0.00
H 1 1.50 250.00 0.00
T 966 15641.60 28945.76 28945.76
5411 18469.19 198124.15 0.00
Other 0 0.00 0.00 0.00
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Total 10123 73728.36 343073.75 133685.10