CMS/EIP Fiscal Report Center: 02
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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 170 87.25 3228.25 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 128 284.25 10489.50 36.90
TCON-TCON-TRANSITION CONFERENCE 27 27.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 354 746.00 22357.25 29.97
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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 1 2.00 150.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.00 111.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 28 51.50 3827.50 74.32
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 12.00 900.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.00 150.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 17 32.50 1803.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 14 27.50 2025.00 73.64
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 2 2.00 52.00 26.00
Subtotal (Total Children Is Unduplicated) 71 185.50 11719.25 63.18
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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
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Total 81724.50 131590.47 1.61
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Number of Children (Unduplicated) With at Least One Service 506
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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 902 47080.75 61995.20 61995.20
1583 34643.75 69595.27 0.00
Other 0 0.00 0.00 0.00
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Total 2485 81724.50 131590.47 61995.20