CMS/EIP Fiscal Report Center: 07
Services beginning 01/01/2010 ending 03/31/2010 Date of Report:05/17/2010 Page: 1
Agency Filter:EIP DEI DEIP
Payclass Filters:GR
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 1110 906.75 33549.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 210 219.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 600 857.75 31700.25 36.96
TCM-T1017TL-TARGETED CASE MANAGEMENT 851 2418.00 89438.25 36.99
TCON-TCON-TRANSITION CONFERENCE 39 39.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1454 4440.50 154688.25 34.84
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 0.75 37.50 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 8 19.00 950.00 50.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 14.00 1050.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 4.00 222.00 55.50
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 13 26.00 1443.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 54 173.50 13012.50 75.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 2 2.00 145.56 72.78
NUTR-97802-NUTRITIONAL EVAL, INITIAL 5 5.25 262.50 50.00
SCREEN-T1023-INTERDISCIPLINARY SCREENING 7 7.00 350.00 50.00
Subtotal (Total Children Is Unduplicated) 81 251.50 17473.06 69.48
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 2 0.75 37.50 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 2 1.50 75.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 5 2.75 68.75 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 11 7.75 387.50 50.00
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 1.00 50.00 50.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 61 3820.00 1877.50 0.49
Subtotal (Total Children Is Unduplicated) 73 3833.75 2496.25 0.65
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Total 8525.75 174657.56 20.49
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Number of Children (Unduplicated) With at Least One Service 1455
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Center 07
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 3 2.75 101.75 0.00
P 0 0.00 0.00 0.00
D 14 6.75 249.75 0.00
S 22 8.00 296.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
8673 8508.25 174010.06 0.00
Other 0 0.00 0.00 0.00
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Total 8712 8525.75 174657.56 0.00