CMS/EIP Fiscal Report Center: 57
Services beginning 01/01/2010 ending 03/31/2010 Date of Report:05/17/2010 Page: 1
Agency Filter:EXT
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
TCM-T1017TL-TARGETED CASE MANAGEMENT 3 4.50 166.50 37.00
Subtotal (Total Children Is Unduplicated) 3 4.50 166.50 37.00
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Screening, Eval, and Assessment,Class #02
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) 2 2.00 97.00 48.50
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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 43 2302.00 1151.00 0.50
Subtotal (Total Children Is Unduplicated) 66 2717.50 7936.26 2.92
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Total 2724.00 8199.76 3.01
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Number of Children (Unduplicated) With at Least One Service 70
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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 0 0.00 0.00 0.00
85 2562.50 5819.10 0.00
Other 37 161.50 2380.66 2380.66
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Total 122 2724.00 8199.76 2380.66