CMS/EIP Fiscal Report Center: 52
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 436 267.25 9888.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 393 516.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 397 305.50 11303.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 764 2595.75 95711.75 36.87
TCON-TCON-TRANSITION CONFERENCE 89 90.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 778 3774.50 116903.50 30.97
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-TRANSITION ASSESSMENT 6 9.75 487.50 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 8.50 512.50 60.29
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.50 112.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.00 150.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.00 225.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 9.00 499.50 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 22 24.00 1100.00 45.83
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 118 180.54 12209.50 67.63
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 19 31.00 2097.00 67.65
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 29 40.00 3000.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 101 158.50 8780.25 55.40
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 23 35.50 2662.50 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 20 20.00 970.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 18 18.00 873.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 13 13.00 650.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 48 48.00 2328.00 48.50
VISF-VISF-VISION EVALUATION FUNCTIONAL 1 0.50 25.00 50.00
Subtotal (Total Children Is Unduplicated) 243 602.79 36682.25 60.85
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 4.00 60.00 15.00
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 68 85.25 4237.50 49.71
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 21 17.75 887.50 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 2 0.50 12.50 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 2 2.00 100.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 5 3.25 81.25 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 16 10.00 500.00 50.00
CONPP-CONPP-CONSULT, PT, PHONE 5 1.75 43.75 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 15 16.00 800.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 10 5.50 137.50 25.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 66 274.50 8275.00 30.15
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 141 650.00 31622.50 48.65
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 4 27.00 1350.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 120 677.15 46150.64 68.15
OCCT-97530HM-OT SESSION BY OT ASST 4 31.50 1711.08 54.32
PHY-97110-PT SESSION BY LICENSED PT 125 664.26 45113.50 67.92
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 2 7.50 375.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 342 1752.01 119075.41 67.97
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 528 119186 59593.00 0.50
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 11 27.75 1387.50 50.00
Subtotal (Total Children Is Unduplicated) 572 123444 321513.63 2.60
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Total 127820.96 475099.38 3.72
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Number of Children (Unduplicated) With at Least One Service 793
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Center 52
Flag Claims Units Chgs Paid
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R 234 178.00 9026.76 0.00
U 0 0.00 0.00 0.00
B 953 633.75 29372.97 0.00
P 2063 38106.90 80839.12 80839.12
D 0 0.00 0.00 0.00
S 87 66.50 2312.50 0.00
H 64 120.50 8354.97 0.00
T 0 0.00 0.00 0.00
6974 88715.31 345193.06 0.00
Other 0 0.00 0.00 0.00
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Total 10375 127820.96 475099.38 80839.12