CMS/EIP Fiscal Report Center: 02
Services beginning 01/01/2010 ending 03/31/2010 Date of Report:05/17/2010 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 188 70.00 2580.75 36.87
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 126 126.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 161 267.75 9879.00 36.90
TCM-T1017TL-TARGETED CASE MANAGEMENT 165 452.25 16603.75 36.71
TCON-TCON-TRANSITION CONFERENCE 24 24.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 408 940.00 29063.50 30.92
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 2.00 100.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 32 58.50 2925.00 50.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 32 57.50 4256.50 74.03
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 12 21.00 1575.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.00 150.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 30 57.00 3163.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 16.50 1237.50 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.00 26.50 26.50
Subtotal (Total Children Is Unduplicated) 85 217.50 13531.00 62.21
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 8 11.00 2103.30 191.21
AUD-HA_FUP-AUDIOLOGY SERVICES 1 2.00 67.39 33.70
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 11 12.00 600.00 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 1 2.00 50.00 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 24 19.00 950.00 50.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 4 5.00 250.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 12 8.50 425.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 75 496.75 24837.50 50.00
INTR-INTR-INTERPRETER 3 6.25 312.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 30 145.00 8689.76 59.93
OCCT-97530HM-OT SESSION BY OT ASST 2 3.50 190.12 54.32
PHY-97110-PT SESSION BY LICENSED PT 13 56.75 3576.75 63.03
PHY-97110HM-PT SESSION BY PT ASST 1 1.50 75.42 50.28
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 55 415.00 26951.67 64.94
SPL-92508-GROUP SPL SESSION PER CHILD 1 2.00 26.40 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 318 85328.0 42664.00 0.50
Subtotal (Total Children Is Unduplicated) 331 86514.3 111769.81 1.29
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Total 87671.75 154364.31 1.76
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Number of Children (Unduplicated) With at Least One Service 555
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Center 02
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 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 1032 45779.25 64274.30 64274.30
2018 41892.50 90090.01 0.00
Other 0 0.00 0.00 0.00
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Total 3050 87671.75 154364.31 64274.30