CMS/EIP Fiscal Report Center: 57
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 248 155.50 5753.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 496 504.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 358 301.25 11146.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 728 2695.25 99465.25 36.90
TCON-TCON-TRANSITION CONFERENCE 62 62.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1093 3718.00 116365.00 31.30
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Screening, Eval, and Assessment,Class #02
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.00 60.00 60.00
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 8 12.00 540.00 45.00
EVAL-EVAL-DEVELOPMENTAL EVALUATION 8 10.00 500.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 66 66.00 3300.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 3.50 262.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 0.50 37.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 6.00 333.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 134 171.00 12825.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 146 230.00 12709.50 55.26
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 13 14.00 1050.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 9 9.00 436.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 13 13.00 630.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 6 6.00 291.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 10 10.00 485.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 68 68.00 3288.00 48.35
VISD-VISD-VISION EVALUATION DIAGNOSTIC 1 60.00 30.00 0.50
Subtotal (Total Children Is Unduplicated) 304 680.00 36778.50 54.09
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 5 5.75 287.50 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 491 1041.50 52050.00 49.98
CONIP-CONIP-CONSULT, ITDS, PHONE 165 301.50 7537.50 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 6 10.00 500.00 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 11 20.00 1000.00 50.00
CONPP-CONPP-CONSULT, PT, PHONE 3 4.00 100.00 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 479 1003.00 50100.00 49.95
CONSP-CONSP-CONSULT, SLP, PHONE 166 299.00 7475.00 25.00
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 10 38.00 1330.00 35.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 3 11.50 315.00 27.39
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 13 46.00 2300.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 388 3154.00 157700.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 47 144.50 9808.66 67.88
PHY-97110-PT SESSION BY LICENSED PT 49 164.25 10993.41 66.93
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 225 947.50 63727.40 67.26
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 4.00 135.76 33.94
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.50 19.80 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 744 156306 80383.59 0.51
Subtotal (Total Children Is Unduplicated) 872 163502 445763.62 2.73
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Total 167900.00 598907.12 3.57
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Number of Children (Unduplicated) With at Least One Service 1398
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Center 57
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 62 62.75 2858.00 0.00
S 29 708.50 1643.96 1643.96
H 0 0.00 0.00 0.00
T 6751 162414.00 448361.68 448723.00
4210 4713.75 145993.48 1229.98
Other 1 1.00 50.00 50.00
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Total 11053 167900.00 598907.12 451646.94