CMS/EIP Fiscal Report Center: 52
Services beginning 04/01/2010 ending 06/30/2010 Date of Report:08/18/2010 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 449 222.75 8234.50 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 363 1027.25 37888.00 36.88
TCON-TCON-TRANSITION CONFERENCE 85 85.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 749 2122.75 56473.25 26.60
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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
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 17 18.00 883.25 49.07
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 19 29.00 2175.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 10.67 800.00 74.98
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 6 8.50 471.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 7.50 562.50 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 7 7.00 339.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 4 4.00 194.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 4 4.00 175.00 43.75
SPCH-92506-SPEECH EVAL BY LICENSED SLP 23 22.80 1105.43 48.48
Subtotal (Total Children Is Unduplicated) 90 119.47 7106.43 59.48
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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 53 60.00 3000.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 37 34.00 1700.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 6 2.50 62.50 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 7.00 350.00 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 2 6.00 150.00 25.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 1.00 50.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 28 132.00 6600.00 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 2 6.00 300.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 38 192.04 13030.68 67.85
OCCT-97530HM-OT SESSION BY OT ASST 5 63.28 3437.22 54.32
PHY-97110-PT SESSION BY LICENSED PT 39 245.12 16633.76 67.86
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 4.00 200.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 144 780.08 52942.73 67.87
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 602 139323 69661.50 0.50
Subtotal (Total Children Is Unduplicated) 615 140908 170561.56 1.21
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Total 143149.74 234141.24 1.64
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Number of Children (Unduplicated) With at Least One Service 820
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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 0 0.00 0.00 0.00
P 718 37073.24 48162.57 48162.57
D 1 2.00 100.00 0.00
S 1 1.00 67.88 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
5789 106073.50 185810.79 0.00
Other 0 0.00 0.00 0.00
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Total 6509 143149.74 234141.24 48162.57