CMS/EIP Fiscal Report Center: 55
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 248 157.25 5762.75 36.65
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 396 538.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 97 69.00 2553.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 290 936.00 34558.00 36.92
TCON-TCON-TRANSITION CONFERENCE 35 35.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 580 1735.25 42873.75 24.71
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 3 5.00 625.00 125.00
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 2.00 111.00 55.50
EXIT-EXIT-TRANSITION ASSESSMENT 7 7.00 350.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 3.00 225.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 2.00 150.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 69 84.90 6367.23 75.00
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 6 6.00 450.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 27 50.00 2775.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 30 31.00 2325.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 2 2.00 97.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 4 4.00 194.00 48.50
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
SPCH-92506-SPEECH EVAL BY LICENSED SLP 13 13.00 630.50 48.50
Subtotal (Total Children Is Unduplicated) 134 222.40 15157.73 68.16
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 3 3.00 478.22 159.41
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 2 1.50 75.00 50.00
CONPP-CONPP-CONSULT, PT, PHONE 5 4.00 100.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 29 189.50 8985.00 47.41
INTR-INTR-INTERPRETER 1 4.00 180.00 45.00
OCCT-97530-OT SESSION BY LICENSED OT 32 143.48 9738.85 67.88
OCCT-97530HM-OT SESSION BY OT ASST 7 38.22 2075.98 54.32
PHY-97110-PT SESSION BY LICENSED PT 26 106.72 7243.47 67.87
PHY-97110HM-PT SESSION BY PT ASST 9 26.00 1411.60 54.29
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 138 799.33 54258.78 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 368 85558.0 64751.60 0.76
Subtotal (Total Children Is Unduplicated) 399 86880.8 149611.00 1.72
----------------------------------------------------------------------------------------------------------------
Total 88838.40 207642.48 2.34
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 682
----------------------------------------------------------------------------------------------------------------
Center 55
Flag Claims Units Chgs Paid
-------------------------------------------------
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 1542 26549.18 43155.35 43155.35
D 55 55.00 3337.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 3899 60483.72 116566.70 116566.70
2115 1750.50 44583.43 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 7611 88838.40 207642.48 159722.05