CMS/EIP Fiscal Report Center: 55
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 202 96.25 3552.00 36.90
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 281 361.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 88 62.25 2303.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 275 844.25 30895.00 36.59
TCON-TCON-TRANSITION CONFERENCE 35 35.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 483 1398.75 36750.25 26.27
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 2 8.00 400.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 5 6.75 387.50 57.41
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 36 54.01 4050.57 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 19 31.59 2368.64 74.98
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 4.50 337.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 21 40.50 2247.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 11.50 862.50 75.00
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 0.17 8.21 48.29
SPCH-92506-SPEECH EVAL BY LICENSED SLP 13 13.00 630.50 48.50
Subtotal (Total Children Is Unduplicated) 82 170.02 11293.17 66.42
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 4 4.00 2431.55 607.89
AUD-HA_FUP-AUDIOLOGY SERVICES 1 1.00 50.00 50.00
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 2 1.00 50.00 50.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 2 2.50 125.00 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 2 1.00 50.00 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 1.00 50.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 16 97.75 4887.50 50.00
INTR-INTR-INTERPRETER 1 16.00 708.00 44.25
OCCT-97530-OT SESSION BY LICENSED OT 30 130.47 8854.41 67.87
OCCT-97530HM-OT SESSION BY OT ASST 7 39.00 2118.48 54.32
PHY-97110-PT SESSION BY LICENSED PT 29 66.96 4543.73 67.86
PHY-97110HM-PT SESSION BY PT ASST 7 20.96 1132.86 54.05
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 126 619.53 42053.47 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 362 67987.0 51898.09 0.76
Subtotal (Total Children Is Unduplicated) 389 68988.2 118953.09 1.72
----------------------------------------------------------------------------------------------------------------
Total 70556.94 166996.51 2.37
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 622
----------------------------------------------------------------------------------------------------------------
Center 55
Flag Claims Units Chgs Paid
-------------------------------------------------
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 2537 38515.07 73207.46 73207.46
D 42 44.25 1837.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 966 15641.60 28945.76 28945.76
2678 16356.02 63006.29 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 6223 70556.94 166996.51 102153.22