CMS/EIP Fiscal Report Center: 05
Services beginning 01/01/2010 ending 03/31/2010 Date of Report:05/17/2010 Page: 1
Eligibility Filter:DEI Only
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 30 9.25 342.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 15 15.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 5 6.50 240.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 64 170.25 6299.25 37.00
Subtotal (Total Children Is Unduplicated) 64 201.00 6882.00 34.24
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.50 83.25 55.50
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 4 4.00 291.12 72.78
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 6 6.00 300.90 50.15
SCREEN-T1023-INTERDISCIPLINARY SCREENING 9 9.00 450.00 50.00
Subtotal (Total Children Is Unduplicated) 11 20.50 1125.27 54.89
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 4.00 200.00 50.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 2 255.00 127.50 0.50
Subtotal (Total Children Is Unduplicated) 2 259.00 327.50 1.26
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Total 480.50 8334.77 17.35
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Number of Children (Unduplicated) With at Least One Service 64
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Center 05
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 282 142.00 5281.75 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
133 338.50 3053.02 0.00
Other 0 0.00 0.00 0.00
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Total 415 480.50 8334.77 0.00