CMS/EIP Fiscal Report Center: 57
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 Page: 1
Agency Filter:EXT
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
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 7 7.00 0.00 0.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 22 25.00 925.00 37.00
Subtotal (Total Children Is Unduplicated) 26 32.00 925.00 28.91
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 1.00 50.00 50.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.50 112.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.50 83.25 55.50
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) 75 91.37 4483.02 49.06
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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 722 127036 65221.70 0.51
Subtotal (Total Children Is Unduplicated) 858 133069 374048.04 2.81
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Total 133191.89 379456.06 2.85
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Number of Children (Unduplicated) With at Least One Service 897
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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 0 0.00 0.00 0.00
S 197 3883.50 9360.90 9360.90
H 0 0.00 0.00 0.00
T 5403 129247.39 369075.91 369417.61
27 24.00 926.75 250.00
Other 4 37.00 92.50 92.50
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Total 5631 133191.89 379456.06 379121.01