CMS/EIP Fiscal Report Center: 57
Services beginning 04/01/2010 ending 06/30/2010 Date of Report:08/18/2010 Page: 1
Payclass Filters:OTHER
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
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 3 3.00 0.00 0.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 41 156.00 5772.00 37.00
TCON-TCON-TRANSITION CONFERENCE 1 1.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 42 160.00 5772.00 36.08
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 2.00 150.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.00 150.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 69 74.50 5587.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 5.00 375.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 31 46.00 2553.00 55.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 2.00 97.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 2 2.00 97.00 48.50
Subtotal (Total Children Is Unduplicated) 80 133.50 9009.50 67.49
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EI Services,Class #03
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 20 20.25 1012.50 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 2 2.00 50.00 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 7 7.50 375.00 50.00
ECE-ECE-EARLY CHILDHOOD EDUCATION 6 375.00 3375.00 9.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 7 52.00 1300.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 3.00 150.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 5 15.50 1052.14 67.88
PHY-97110-PT SESSION BY LICENSED PT 1 4.00 271.52 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 10.50 712.74 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 44 3295.00 1648.70 0.50
Subtotal (Total Children Is Unduplicated) 81 3784.75 9947.60 2.63
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Total 4078.25 24729.10 6.06
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Number of Children (Unduplicated) With at Least One Service 194
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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 1 3.00 2.70 2.70
H 0 0.00 0.00 0.00
T 2 1.50 75.00 75.00
363 3111.50 21605.46 0.00
Other 54 962.25 3045.94 3045.94
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Total 420 4078.25 24729.10 3123.64