CMS/EIP Fiscal Report Center: 05
Services beginning 01/01/2010 ending 03/31/2010 Date of Report:05/17/2010 Page: 1
Agency Filter:EIP DEI DEIP
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
CASE-CASE-NON-TCM CASE MANAGEMENT 261 114.50 4236.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 337 413.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 373 365.00 13505.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 713 2680.25 99150.75 36.99
Subtotal (Total Children Is Unduplicated) 716 3572.75 116892.25 32.72
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 6.50 487.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.00 55.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 11.00 825.00 75.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 2 2.00 145.56 72.78
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 1 1.00 50.15 50.15
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 3 3.00 150.00 50.00
Subtotal (Total Children Is Unduplicated) 15 25.50 1762.21 69.11
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EI Services,Class #03
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 3 3.00 150.00 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 10 8.50 425.00 50.00
CONPP-CONPP-CONSULT, PT, PHONE 1 0.25 6.25 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4 11.00 550.00 50.00
PHY-97110-PT SESSION BY LICENSED PT 2 5.00 339.40 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 17 960.00 480.00 0.50
Subtotal (Total Children Is Unduplicated) 22 987.75 1950.65 1.97
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Total 4586.00 120605.11 26.30
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Number of Children (Unduplicated) With at Least One Service 716
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Center 05
Flag Claims Units Chgs Paid
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R 58 29.00 1073.00 0.00
U 0 0.00 0.00 0.00
B 2202 1196.25 44279.75 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
3927 3360.75 75252.36 0.00
Other 0 0.00 0.00 0.00
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Total 6187 4586.00 120605.11 0.00