CMS/EIP Fiscal Report Center: 09
Services beginning 07/01/2009 ending 09/30/2009 Date of Report:11/17/2009 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 801 805.00 29785.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 701 804.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 689 688.00 25456.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1703 4881.00 180587.75 37.00
TCON-TCON-TRANSITION CONFERENCE 121 122.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1845 7300.00 235828.75 32.31
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 2.75 137.50 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 12 22.50 1125.00 50.00
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 1 1.00 55.50 55.50
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 78 133.50 9938.50 74.45
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 21 35.00 2625.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 27 36.00 2700.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 35 68.50 5137.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 22 36.00 1998.00 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 4 4.00 222.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 424 658.50 49279.50 74.84
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 129 212.00 15862.50 74.82
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 217 292.50 21729.84 74.29
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 229 369.50 20507.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 78 116.00 8700.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 4 4.00 194.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 2.00 97.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.00 97.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 12 15.00 750.00 50.00
Subtotal (Total Children Is Unduplicated) 626 2010.75 141156.09 70.20
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.00 1145.50 1145.50
AUD-HA_FUP-AUDIOLOGY SERVICES 1 1.00 50.00 50.00
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 108 132.50 6625.00 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 2 2.00 50.00 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 12 25.75 1287.50 50.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 49 49.25 2462.50 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 23 51.50 2575.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 37 56.75 2837.50 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 441 3388.00 168340.00 49.69
INTR-INTR-INTERPRETER 12 12.00 600.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 392 2706.50 179567.62 66.35
PHY-97110-PT SESSION BY LICENSED PT 337 2058.25 136142.55 66.14
PHY-97110HM-PT SESSION BY PT ASST 9 67.00 3639.44 54.32
SENS-V5264-EARMOLD 5 10.00 187.20 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 670 4659.50 314496.60 67.50
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 844 215219 107609.50 0.50
Subtotal (Total Children Is Unduplicated) 1269 228440 927615.91 4.06
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Total 237750.75 1304600.75 5.49
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Number of Children (Unduplicated) With at Least One Service 2152
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Center 09
Flag Claims Units Chgs Paid
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R 15 16.00 629.00 27.75
U 0 0.00 0.00 0.00
B 1024 983.50 50177.64 335.00
P 11447 143015.75 563093.77 566743.70
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 1 0.50 18.50 18.50
T 4866 82007.25 265663.66 265663.66
3657 11727.75 425018.18 1989.75
Other 0 0.00 0.00 0.00
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Total 21010 237750.75 1304600.75 834778.36