CMS/EIP Fiscal Report Center: 57
Services beginning 01/01/2010 ending 03/31/2010 Date of Report:05/17/2010 Page: 1
Payclass Filters:OTHER
Eligibility Filter:Part C (excluding not eligible)
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 1 0.50 18.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 2 2.00 0.00 0.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 46 131.00 4847.00 37.00
Subtotal (Total Children Is Unduplicated) 47 133.50 4865.50 36.45
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 3.00 225.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.00 75.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 4.50 249.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 68 82.50 6187.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 6.00 450.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 7.50 562.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 68 102.50 5688.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 7.00 525.00 75.00
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 83 216.00 14060.50 65.09
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EI Services,Class #03
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 8 8.00 400.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 2 2.00 50.00 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.00 50.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 6 6.00 300.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 2 2.00 50.00 25.00
ECE-ECE-EARLY CHILDHOOD EDUCATION 3 356.00 3204.00 9.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 1.00 50.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 3 9.00 610.92 67.88
PHY-97110-PT SESSION BY LICENSED PT 2 2.50 169.70 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 12 28.00 1900.64 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 44 2322.00 1165.00 0.50
Subtotal (Total Children Is Unduplicated) 67 2737.50 7950.26 2.90
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Total 3087.00 26876.26 8.71
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Number of Children (Unduplicated) With at Least One Service 188
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Center 57
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 1 20.00 14.00 14.00
396 2905.50 24481.60 0.00
Other 37 161.50 2380.66 2380.66
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Total 434 3087.00 26876.26 2394.66