CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 Page: 1
Payclass Filters:TPIN
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 1 0.25 9.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 21 32.25 1193.25 37.00
Subtotal (Total Children Is Unduplicated) 21 32.50 1202.50 37.00
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 2 3.00 122.00 40.67
EXIT-EXIT-TRANSITION ASSESSMENT 3 4.00 200.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.00 225.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 7.00 525.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 5.00 277.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 22 38.50 2887.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 9.00 675.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 11.00 825.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 21 38.00 2109.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 13 23.00 1725.00 75.00
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 0.25 13.98 55.92
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.00 97.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 7 13.00 630.50 48.50
Subtotal (Total Children Is Unduplicated) 56 156.75 10312.48 65.79
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 3 3.00 673.71 224.57
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 7 6.75 337.50 50.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 0.75 37.50 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 0.75 37.50 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.50 75.00 50.00
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 3 9.00 450.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 52 153.50 7975.28 51.96
OCCT-97530-OT SESSION BY LICENSED OT 34 104.25 8229.08 78.94
OCCT-97530HM-OT SESSION BY OT ASST 1 1.00 54.32 54.32
PHY-97110-PT SESSION BY LICENSED PT 79 313.00 25120.25 80.26
PHY-97110HM-PT SESSION BY PT ASST 3 11.00 597.52 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 195 879.75 63631.00 72.33
SPL-92508-GROUP SPL SESSION PER CHILD 2 1.50 19.80 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 6 471.00 235.50 0.50
Subtotal (Total Children Is Unduplicated) 292 1956.75 107473.96 54.92
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Total 2146.00 118988.94 55.45
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Number of Children (Unduplicated) With at Least One Service 342
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Center 01
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 1 1.00 67.88 0.00
D 82 135.00 8924.00 0.00
S 1 0.50 18.50 0.00
H 2 3.50 262.50 0.00
T 0 0.00 0.00 0.00
746 1345.75 66607.60 0.00
Other 467 660.25 43108.46 0.00
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Total 1299 2146.00 118988.94 0.00