CMS/EIP Fiscal Report Center: 02
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 Page: 1
Payclass Filters:GR
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 232 118.00 4366.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 154 168.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 205 307.25 11322.00 36.85
TCM-T1017TL-TARGETED CASE MANAGEMENT 226 522.25 19212.25 36.79
TCON-TCON-TRANSITION CONFERENCE 24 24.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 485 1139.50 34900.25 30.63
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-TRANSITION ASSESSMENT 28 48.75 2437.50 50.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.00 150.00 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 40 71.50 5317.00 74.36
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 18 26.50 1931.92 72.90
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 9.00 675.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 45 81.50 4519.50 55.45
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 17.00 1275.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 2 2.00 78.02 39.01
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 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) 100 264.75 16709.69 63.12
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 3 3.00 696.79 232.26
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 13 12.25 612.50 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 12 12.75 637.50 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 2 1.00 25.00 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 11 9.00 435.00 48.33
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 17 10.75 537.50 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 3 1.25 31.25 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 69 419.75 20946.50 49.90
INTR-INTR-INTERPRETER 7 16.50 790.00 47.88
OCCT-97530-OT SESSION BY LICENSED OT 30 231.50 8966.01 38.73
PHY-97110-PT SESSION BY LICENSED PT 10 42.00 2742.62 65.30
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 51 372.75 24568.72 65.91
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 301 83550.0 41699.01 0.50
Subtotal (Total Children Is Unduplicated) 315 84682.5 102688.40 1.21
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Total 86086.75 154298.34 1.79
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Number of Children (Unduplicated) With at Least One Service 589
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Center 02
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 0 0.00 0.00 0.00
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 1773 60825.25 86393.75 86393.75
1803 25261.50 67904.59 0.00
Other 0 0.00 0.00 0.00
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Total 3576 86086.75 154298.34 86393.75