CMS/EIP Fiscal Report Center: 57
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 Page: 1
Payclass Filters:GR
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
CASE-CASE-NON-TCM CASE MANAGEMENT 187 103.00 3811.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 397 403.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 160 141.50 5235.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 525 1201.25 44446.25 37.00
TCON-TCON-TRANSITION CONFERENCE 47 47.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 827 1895.75 53492.75 28.22
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 13 14.50 725.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 62 62.00 3100.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.00 75.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.50 83.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 133 157.50 11812.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 128 196.50 10905.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 11 19.00 1425.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 14 14.00 679.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 2.37 114.77 48.43
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 7 7.00 339.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 3 3.00 145.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 60 61.00 2958.50 48.50
Subtotal (Total Children Is Unduplicated) 279 539.37 32363.77 60.00
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.00 50.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 477 835.00 41750.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 120 160.50 4012.50 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 5 7.00 350.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 1 1.00 25.00 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 14 26.00 1300.00 50.00
CONPP-CONPP-CONSULT, PT, PHONE 1 0.50 12.50 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 461 798.00 39900.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 118 150.50 3762.50 25.00
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 2 4.00 140.00 35.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 349 2498.00 124900.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 41 144.02 9772.32 67.85
PHY-97110-PT SESSION BY LICENSED PT 32 123.00 8349.24 67.88
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 2 3.00 150.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 233 1093.50 74226.78 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 2 2.50 33.00 13.20
TRAN-TRAN-FAMILY TRANSPORTATION 1 185.00 92.50 0.50
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 725 127306 65356.70 0.51
Subtotal (Total Children Is Unduplicated) 861 133339 374183.04 2.81
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Total 135773.64 460039.56 3.39
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Number of Children (Unduplicated) With at Least One Service 1248
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Center 57
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 10 9.50 483.00 0.00
S 197 3883.50 9360.90 9360.90
H 0 0.00 0.00 0.00
T 5428 129266.64 369455.16 370129.86
2340 2577.00 80648.00 250.00
Other 4 37.00 92.50 92.50
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Total 7979 135773.64 460039.56 379833.26