CMS/EIP Fiscal Report Center: 02
Services beginning 07/01/2009 ending 09/30/2009 Date of Report:11/17/2009 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 211 94.50 3487.25 36.90
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 138 139.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 168 278.25 10239.75 36.80
TCM-T1017TL-TARGETED CASE MANAGEMENT 157 353.00 12913.00 36.58
TCON-TCON-TRANSITION CONFERENCE 25 25.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 426 889.75 26640.00 29.94
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 2.00 100.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 23 43.50 2175.00 50.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.50 112.50 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 25 42.50 3037.50 71.47
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 15 23.50 1734.71 73.82
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 22 41.00 2275.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 7.50 562.50 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.00 48.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 66 164.50 10143.21 61.66
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 3 3.00 136.83 45.61
AUD-HA_FUP-AUDIOLOGY SERVICES 1 2.00 55.38 27.69
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 11 12.25 612.50 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 1 0.50 12.50 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 15 14.00 700.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 2 0.75 18.75 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 11 7.75 387.50 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 8 8.00 400.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 1 0.50 12.50 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 70 439.50 21975.00 50.00
INTR-INTR-INTERPRETER 5 14.00 700.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 27 131.00 8696.84 66.39
PHY-97110-PT SESSION BY LICENSED PT 7 24.75 1528.82 61.77
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 38 266.25 17576.64 66.02
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 310 81401.0 40700.50 0.50
Subtotal (Total Children Is Unduplicated) 325 82325.3 93513.76 1.14
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Total 83379.50 130296.97 1.56
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Number of Children (Unduplicated) With at Least One Service 543
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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 1840 70360.25 86483.71 86483.71
1345 13019.25 43813.26 0.00
Other 0 0.00 0.00 0.00
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Total 3185 83379.50 130296.97 86483.71