CMS/EIP Fiscal Report Center: 05
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 255 119.75 4430.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 311 368.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 373 334.50 12376.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 759 2701.50 99955.50 37.00
Subtotal (Total Children Is Unduplicated) 760 3523.75 116762.75 33.14
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Screening, Eval, and Assessment,Class #02
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.00 31.81 31.81
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 3.00 150.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 31 56.50 2825.00 50.00
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 9 9.50 527.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 26 48.20 2775.00 57.57
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 4.00 300.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 16 21.50 1537.50 71.51
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 48 78.50 4356.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 13 22.50 1687.50 75.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 3 3.00 218.34 72.78
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 6 6.00 300.90 50.15
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 4.00 194.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.00 97.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 8 8.00 400.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 5 5.00 242.50 48.50
Subtotal (Total Children Is Unduplicated) 136 272.70 15643.55 57.37
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 46 48.25 2412.50 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 281 393.75 19687.50 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 17 6.75 168.75 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 47 23.50 1175.00 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 96 52.00 2600.00 50.00
CONPP-CONPP-CONSULT, PT, PHONE 1 0.50 12.50 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 151 162.00 8100.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 6 1.75 43.75 25.00
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 11 31.00 665.96 21.48
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 15 60.50 1467.38 24.25
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 87 414.25 18317.82 44.22
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 224 1239.25 61158.18 49.35
INTR-INTR-INTERPRETER 6 37.50 1875.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 46 146.25 7891.05 53.96
PHY-97110-PT SESSION BY LICENSED PT 82 352.54 18442.68 52.31
PHY-97110HM-PT SESSION BY PT ASST 3 5.00 271.60 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 120 406.95 24661.34 60.60
SPL-92508-GROUP SPL SESSION PER CHILD 7 11.03 152.75 13.85
TRAN-TRAN-FAMILY TRANSPORTATION 2 12.00 170.58 14.22
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 446 99897.0 49948.50 0.50
Subtotal (Total Children Is Unduplicated) 506 103302 219222.84 2.12
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Total 107098.22 351629.14 3.28
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Number of Children (Unduplicated) With at Least One Service 776
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Center 05
Flag Claims Units Chgs Paid
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R 149 95.75 3542.75 0.00
U 0 0.00 0.00 0.00
B 2040 1074.00 39922.15 0.00
P 1566 40774.77 68738.80 68738.80
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 0 0.00 0.00 0.00
7538 65153.70 239425.44 0.00
Other 0 0.00 0.00 0.00
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Total 11293 107098.22 351629.14 68738.80