CMS/EIP Fiscal Report Center: 05
Services beginning 01/01/2010 ending 03/31/2010 Date of Report:05/17/2010 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 302 129.50 4791.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 352 428.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 409 410.00 15170.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 816 3031.25 112137.75 36.99
Subtotal (Total Children Is Unduplicated) 819 3998.75 132099.25 33.04
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-TRANSITION ASSESSMENT 30 51.25 2562.50 50.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.00 150.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 10.00 555.00 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 16 25.00 1387.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 17 31.00 2175.00 70.16
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 9.50 712.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 17 22.50 1687.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 48 83.00 4606.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 21 30.50 2287.50 75.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 6 6.00 436.68 72.78
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 7 7.00 351.05 50.15
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 9 12.00 436.50 36.38
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.00 97.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 12 12.00 600.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 7 8.00 388.00 48.50
Subtotal (Total Children Is Unduplicated) 160 312.75 18481.73 59.09
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 47 50.75 2537.50 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 258 244.50 12225.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 24 9.00 225.00 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 50 25.00 1250.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 1 0.50 12.50 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 91 51.25 2562.50 50.00
CONPP-CONPP-CONSULT, PT, PHONE 1 0.25 6.25 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 127 123.25 6162.50 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 5 1.50 37.50 25.00
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 13 41.25 962.63 23.34
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 4 15.25 353.99 23.21
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 86 274.00 12173.62 44.43
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 263 1452.00 72490.32 49.92
INTR-INTR-INTERPRETER 8 56.75 2837.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 63 160.46 10499.13 65.43
OCCT-97530HM-OT SESSION BY OT ASST 4 3.50 190.12 54.32
PHY-97110-PT SESSION BY LICENSED PT 90 362.93 20983.90 57.82
PHY-97110HM-PT SESSION BY PT ASST 1 0.50 27.16 54.32
SENS-V5264-EARMOLD 1 2.00 37.44 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 157 471.00 31564.20 67.02
SPL-92508-GROUP SPL SESSION PER CHILD 2 39.00 514.80 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 431 92834.0 46417.00 0.50
Subtotal (Total Children Is Unduplicated) 491 96218.6 224070.56 2.33
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Total 100530.14 374651.54 3.73
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Number of Children (Unduplicated) With at Least One Service 823
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Center 05
Flag Claims Units Chgs Paid
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R 78 42.25 1563.25 0.00
U 0 0.00 0.00 0.00
B 2607 1433.75 53095.00 0.00
P 1042 22640.58 43453.11 43453.11
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 0 0.00 0.00 0.00
8633 76413.56 276540.18 0.00
Other 0 0.00 0.00 0.00
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Total 12360 100530.14 374651.54 43453.11