CMS/EIP Fiscal Report Center: 51
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 Page: 1
Payclass Filters:GR
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 397 313.75 11608.75 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 296 410.00 15170.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 340 1329.00 49154.50 36.99
Subtotal (Total Children Is Unduplicated) 654 2052.75 75933.25 36.99
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Screening, Eval, and Assessment,Class #02
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 4 4.00 500.00 125.00
EVAL-EVAL-DEVELOPMENTAL EVALUATION 4 4.00 200.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.50 75.00 50.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.00 75.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.50 75.00 50.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 43 44.50 3236.50 72.73
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 10 10.50 723.50 68.90
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 4.50 225.00 50.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 5 7.00 375.00 53.57
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 51 54.00 3825.00 70.83
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 4 4.00 162.00 40.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 14 15.00 727.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 6 6.00 291.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 24 26.00 1261.00 48.50
VISF-VISF-VISION EVALUATION FUNCTIONAL 1 2.00 140.00 70.00
Subtotal (Total Children Is Unduplicated) 102 186.50 11966.50 64.16
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 5 14.00 4321.17 308.66
AUD-92630-AUD REHAB PRELING HEARING LOSS 1 2.00 137.72 68.86
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 17 19.25 869.50 45.17
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 4 3.00 150.00 50.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 8 5.75 287.50 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 0.50 25.00 50.00
CONPP-CONPP-CONSULT, PT, PHONE 6 2.00 50.00 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 11 8.75 437.50 50.00
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 9 180.50 9012.50 49.93
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 79 491.50 24575.00 50.00
INTR-INTR-INTERPRETER 9 25.75 644.50 25.03
OCCT-97530-OT SESSION BY LICENSED OT 41 248.25 16111.79 64.90
OCCT-97530HM-OT SESSION BY OT ASST 1 1.00 54.32 54.32
PHY-97110-PT SESSION BY LICENSED PT 28 157.00 9073.72 57.79
PHY-97110HM-PT SESSION BY PT ASST 2 6.00 325.92 54.32
SENS-V5264-EARMOLD 1 2.00 37.44 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 107 695.25 45848.73 65.95
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 449 101592 48524.60 0.48
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 3 7.50 445.00 59.33
Subtotal (Total Children Is Unduplicated) 472 103462 160931.91 1.56
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Total 105701.25 248831.66 2.35
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Number of Children (Unduplicated) With at Least One Service 767
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Center 51
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 2161 102343.00 165302.82 165302.82
D 13 10.75 442.75 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
3553 3347.50 83086.09 0.00
Other 0 0.00 0.00 0.00
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Total 5727 105701.25 248831.66 165302.82