CMS/EIP Fiscal Report Center: 05
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 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 383 1451.00 53668.50 36.99
Subtotal (Total Children Is Unduplicated) 718 2418.50 73630.00 30.44
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-TRANSITION ASSESSMENT 30 51.25 2562.50 50.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 4.50 249.75 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 12 17.50 971.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 8 11.49 824.76 71.78
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 6.50 487.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 6.00 450.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 20 32.50 1803.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 18.00 1350.00 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 2.49 103.00 41.37
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 0.34 16.50 48.53
SPCH-92506-SPEECH EVAL BY LICENSED SLP 2 3.00 145.50 48.50
Subtotal (Total Children Is Unduplicated) 86 153.57 8964.51 58.37
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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 11 31.25 712.63 22.80
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 4 15.25 353.99 23.21
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 68 196.50 8298.62 42.23
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 139 714.00 35590.32 49.85
INTR-INTR-INTERPRETER 8 56.75 2837.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 19 49.85 3111.06 62.41
OCCT-97530HM-OT SESSION BY OT ASST 3 2.00 108.64 54.32
PHY-97110-PT SESSION BY LICENSED PT 21 74.84 3484.98 46.57
SENS-V5264-EARMOLD 1 2.00 37.44 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 47 139.52 9418.58 67.51
SPL-92508-GROUP SPL SESSION PER CHILD 1 36.00 475.20 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 430 92278.0 46139.00 0.50
Subtotal (Total Children Is Unduplicated) 483 94102.0 135586.71 1.44
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Total 96674.03 218181.22 2.26
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Number of Children (Unduplicated) With at Least One Service 765
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Center 05
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 12 5.25 194.25 0.00
P 1009 22594.08 41317.11 41317.11
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
6347 74074.70 176669.86 0.00
Other 0 0.00 0.00 0.00
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Total 7368 96674.03 218181.22 41317.11