CMS/EIP Fiscal Report Center: 02
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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 170 89.25 3302.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 113 114.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 136 233.50 8639.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 413 959.25 35149.50 36.64
TCON-TCON-TRANSITION CONFERENCE 27 27.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 474 1423.00 47091.25 33.09
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 2 3.00 150.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 27 51.00 2550.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.00 300.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 4.00 222.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 43 83.50 6227.50 74.58
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 23 39.00 2925.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 15.00 1125.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 38 67.00 3718.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 23 45.50 3375.00 74.18
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 2 2.00 52.00 26.00
Subtotal (Total Children Is Unduplicated) 102 314.00 20645.00 65.75
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.00 80.00 40.00
AUD-HA_FUP-AUDIOLOGY SERVICES 2 4.00 140.23 35.06
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 9 10.00 500.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 21 19.00 950.00 50.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 12 7.75 387.50 50.00
CONOP-CONOP-CONSULT, OT, PHONE 1 3.00 75.00 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 11 11.00 550.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 1 0.25 6.25 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 77 476.50 23825.00 50.00
INTR-INTR-INTERPRETER 6 38.25 675.00 17.65
OCCT-97530-OT SESSION BY LICENSED OT 24 117.25 6823.10 58.19
PHY-97110-PT SESSION BY LICENSED PT 13 65.75 4223.23 64.23
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 43 289.25 19404.16 67.08
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 317 79749.0 39874.50 0.50
Subtotal (Total Children Is Unduplicated) 337 80793.0 97513.97 1.21
----------------------------------------------------------------------------------------------------------------
Total 82530.00 165250.22 2.00
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 589
----------------------------------------------------------------------------------------------------------------
Center 02
Flag Claims Units Chgs Paid
-------------------------------------------------
R 17 13.50 499.50 0.00
U 0 0.00 0.00 0.00
B 716 603.00 22042.25 0.00
P 1 0.50 18.50 0.00
D 0 0.00 0.00 0.00
S 1 1.25 46.25 0.00
H 0 0.00 0.00 0.00
T 902 47080.75 61995.20 61995.20
1701 34831.00 80648.52 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 3338 82530.00 165250.22 61995.20