CMS/EIP Fiscal Report Center: 52
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 Page: 1
Payclass Filters:OTHER
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
TCM-T1017TL-TARGETED CASE MANAGEMENT 4 2.00 74.00 37.00
Subtotal (Total Children Is Unduplicated) 4 2.00 74.00 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.00 150.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 4.50 337.50 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
VISF-VISF-VISION EVALUATION FUNCTIONAL 1 0.50 25.00 50.00
Subtotal (Total Children Is Unduplicated) 7 9.00 609.50 67.72
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.00 15.00 15.00
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 5 7.00 350.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 2 0.50 25.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 1 0.50 12.50 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 4 2.50 125.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 0.50 25.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 2 1.00 25.00 25.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 1.00 30.00 30.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 9 6.00 300.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 7 21.25 1442.45 67.88
PHY-97110-PT SESSION BY LICENSED PT 3 13.75 933.35 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 20 29.76 2019.94 67.87
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 43 1598.00 799.00 0.50
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 11 27.75 1387.50 50.00
Subtotal (Total Children Is Unduplicated) 88 1710.51 7489.74 4.38
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Total 1721.51 8173.24 4.75
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Number of Children (Unduplicated) With at Least One Service 97
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Center 52
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 26 50.75 3418.92 0.00
T 0 0.00 0.00 0.00
130 1670.76 4754.32 0.00
Other 0 0.00 0.00 0.00
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Total 156 1721.51 8173.24 0.00