CMS/EIP Fiscal Report Center: 55
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 250 157.75 5781.25 36.65
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 397 540.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 97 69.00 2553.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 691 2271.25 83666.25 36.84
TCON-TCON-TRANSITION CONFERENCE 35 35.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 694 3073.00 92000.50 29.94
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Screening, Eval, and Assessment,Class #02
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 4 6.00 750.00 125.00
EVAL-EVAL-DEVELOPMENTAL EVALUATION 4 12.00 661.00 55.08
EXIT-EXIT-TRANSITION ASSESSMENT 8 9.00 450.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 9.00 675.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.50 262.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 5.50 587.50 106.82
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 4.00 222.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 169 230.47 17285.06 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 39 71.50 5362.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 31 34.00 2550.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 60 105.00 5827.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 128 133.50 12775.00 95.69
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 6 6.00 291.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 21 22.00 1067.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 6 6.00 291.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 13 14.00 679.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 38 38.00 1843.00 48.50
Subtotal (Total Children Is Unduplicated) 283 709.47 51579.06 72.70
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 4 4.00 636.34 159.09
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 6 4.00 200.00 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 1 1.00 25.00 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 2 1.00 50.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 1 0.50 12.50 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 0.50 25.00 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 3 2.00 100.00 50.00
CONPP-CONPP-CONSULT, PT, PHONE 5 4.00 100.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 82 533.50 26185.00 49.08
INTR-INTR-INTERPRETER 1 4.00 180.00 45.00
OCCT-97530-OT SESSION BY LICENSED OT 105 647.25 43935.33 67.88
OCCT-97530HM-OT SESSION BY OT ASST 18 81.00 4399.92 54.32
PHY-97110-PT SESSION BY LICENSED PT 66 356.00 24165.28 67.88
PHY-97110HM-PT SESSION BY PT ASST 21 73.00 3965.36 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 323 1985.70 134789.68 67.88
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 2 3.00 162.96 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 4 7.00 92.40 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 368 85558.0 64751.60 0.76
Subtotal (Total Children Is Unduplicated) 455 89265.5 303776.37 3.40
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Total 93047.92 447355.93 4.81
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Number of Children (Unduplicated) With at Least One Service 780
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Center 55
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 5 4.50 166.50 0.00
P 2904 27825.43 93653.60 93528.60
D 55 55.00 3337.00 0.00
S 1 0.50 18.50 0.00
H 17 17.00 4075.00 0.00
T 3899 60483.72 116566.70 116566.70
5831 4661.77 229538.63 0.00
Other 0 0.00 0.00 0.00
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Total 12712 93047.92 447355.93 210095.30