CMS/EIP Fiscal Report Center: 51
Services beginning 01/01/2010 ending 03/31/2010 Date of Report:05/17/2010 Page: 1
Eligibility Filter:Not Part C
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 21 14.50 536.50 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 30 33.50 1239.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 55 283.50 10489.50 37.00
Subtotal (Total Children Is Unduplicated) 55 331.50 12265.50 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.00 75.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 22 24.50 1800.00 73.47
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 6.00 450.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 2.50 187.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 5.00 300.00 60.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 28 29.50 2175.00 73.73
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 2 2.00 81.00 40.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 34 72.50 5192.00 71.61
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EI Services,Class #03
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 27 1236.00 618.00 0.50
Subtotal (Total Children Is Unduplicated) 27 1236.00 618.00 0.50
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Total 1640.00 18075.50 11.02
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Number of Children (Unduplicated) With at Least One Service 55
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Center 51
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 177 166.75 6207.75 0.00
P 64 1261.00 2343.00 2343.00
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
237 212.25 9524.75 0.00
Other 0 0.00 0.00 0.00
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Total 478 1640.00 18075.50 2343.00