CMS/EIP Fiscal Report Center: 57
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 194 110.50 4088.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 435 442.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 170 151.00 5587.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 975 2311.50 85525.50 37.00
TCON-TCON-TRANSITION CONFERENCE 47 47.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1085 3062.00 95201.00 31.09
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 16 18.00 900.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 62 62.00 3100.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 9 10.50 787.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.00 150.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 7 9.00 499.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 271 319.50 23962.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 260 390.00 21645.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 21 34.50 2587.50 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 18 18.00 873.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 10 10.00 485.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 11 11.00 533.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 13 13.00 630.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 117 118.00 5723.00 48.50
Subtotal (Total Children Is Unduplicated) 488 1016.50 61952.00 60.95
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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 479 860.00 43000.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 125 169.50 4237.50 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 463 821.00 41050.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 122 157.00 3925.00 25.00
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 2 4.00 140.00 35.00
ECE-ECE-EARLY CHILDHOOD EDUCATION 80 12384.0 111456.00 9.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 9 353.00 8825.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 705 5350.00 267420.00 49.99
OCCT-97530-OT SESSION BY LICENSED OT 143 670.00 45479.60 67.88
PHY-97110-PT SESSION BY LICENSED PT 136 562.00 38148.56 67.88
PHY-97110HM-PT SESSION BY PT ASST 1 1.00 54.32 54.32
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 4 5.00 250.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 431 1971.00 133691.58 67.83
SPL-92508-GROUP SPL SESSION PER CHILD 10 25.00 330.00 13.20
TRAN-TRAN-FAMILY TRANSPORTATION 1 185.00 92.50 0.50
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 756 130129 66768.20 0.51
Subtotal (Total Children Is Unduplicated) 1009 153682 766605.76 4.99
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Total 157760.50 923758.76 5.86
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Number of Children (Unduplicated) With at Least One Service 1432
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Center 57
Flag Claims Units Chgs Paid
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R 187 184.00 6892.75 0.00
U 0 0.00 0.00 0.00
B 976 1007.00 41586.00 0.00
P 1 2.00 74.00 74.00
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 5438 129297.64 371110.94 371785.64
4844 23029.36 490597.39 195669.00
Other 90 347.50 3653.78 3653.78
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Total 11743 157760.50 923758.76 580543.32