CMS/EIP Fiscal Report Center: 52
Services beginning 04/01/2010 ending 06/30/2010 Date of Report:08/18/2010 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 450 223.00 8243.75 36.97
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 387 508.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 343 279.75 10350.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 811 2371.00 87597.50 36.95
TCON-TCON-TRANSITION CONFERENCE 85 85.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 829 3466.75 106192.00 30.63
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-TRANSITION ASSESSMENT 4 5.00 250.00 50.00
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 3 3.00 150.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 9.50 712.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 2.00 150.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 7 10.00 555.00 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 24 29.50 1266.50 42.93
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 148 223.50 16562.50 74.11
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 10 16.50 1237.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 58 83.50 6262.25 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 162 254.50 14124.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 28 43.50 3262.50 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 22 22.00 1067.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 15 15.00 727.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 23 23.00 1125.00 48.91
SPCH-92506-SPEECH EVAL BY LICENSED SLP 53 53.00 2570.50 48.50
Subtotal (Total Children Is Unduplicated) 319 793.50 50023.50 63.04
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 2.00 826.00 413.00
AUD-HA_FUP-AUDIOLOGY SERVICES 2 2.00 76.92 38.46
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 55 62.25 3112.50 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 37 34.25 1712.50 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 7 2.75 68.75 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 9 6.50 325.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 8 3.75 93.75 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 7 7.25 362.50 50.00
CONPP-CONPP-CONSULT, PT, PHONE 10 4.25 106.25 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 16 16.25 812.50 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 11 4.75 118.75 25.00
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 5 12.00 84.00 7.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 6 22.00 550.00 25.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 57 292.25 14612.50 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 147 766.25 38262.50 49.93
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 6 36.00 1800.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 105 620.03 42090.51 67.88
OCCT-97530HM-OT SESSION BY OT ASST 7 101.75 5894.95 57.94
PHY-97110-PT SESSION BY LICENSED PT 127 790.01 53628.64 67.88
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 3 17.00 850.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 364 2240.90 152102.36 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 6 46.75 617.10 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 606 140402 70201.00 0.50
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 9 31.00 1550.00 50.00
Subtotal (Total Children Is Unduplicated) 642 145524 389858.98 2.68
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Total 149784.19 546074.48 3.65
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Number of Children (Unduplicated) With at Least One Service 856
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Center 52
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 92 77.50 4542.67 0.00
P 3494 38924.46 129839.44 129746.94
D 1 2.00 100.00 0.00
S 2 1.25 77.13 0.00
H 41 101.75 6240.14 0.00
T 0 0.00 0.00 0.00
7368 110677.23 405275.10 0.00
Other 0 0.00 0.00 0.00
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Total 10998 149784.19 546074.48 129746.94