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: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 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 384 1312.00 48361.00 36.86
TCON-TCON-TRANSITION CONFERENCE 89 90.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 734 2490.75 69552.75 27.92
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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 1 1.00 75.00 75.00
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 21 23.00 1050.00 45.65
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 20 34.02 2384.92 70.10
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 8.50 472.00 55.53
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 5.00 375.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 11 18.00 988.00 54.89
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 6.00 450.00 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 7 7.00 339.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 5 5.00 242.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 2 2.00 100.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 9 9.00 436.50 48.50
Subtotal (Total Children Is Unduplicated) 76 128.27 7400.92 57.70
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 3.00 45.00 15.00
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 65 75.75 3787.50 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 20 17.25 862.50 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 2.75 68.75 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 14 7.50 375.00 50.00
CONPP-CONPP-CONSULT, PT, PHONE 5 1.75 43.75 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 15 15.50 775.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 9 4.50 112.50 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 39 145.05 7252.50 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 2 11.00 550.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 49 248.19 16842.82 67.86
PHY-97110-PT SESSION BY LICENSED PT 38 179.14 12157.83 67.87
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 1.50 75.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 136 619.77 42066.29 67.87
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 526 117588 58794.00 0.50
Subtotal (Total Children Is Unduplicated) 547 118923 143920.94 1.21
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Total 121542.17 220874.61 1.82
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Number of Children (Unduplicated) With at Least One Service 768
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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 747 37329.98 50946.90 50946.90
D 0 0.00 0.00 0.00
S 5 4.25 83.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
5573 84207.94 169844.46 0.00
Other 0 0.00 0.00 0.00
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Total 6325 121542.17 220874.61 50946.90