CMS/EIP Fiscal Report Center: 51
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 322 223.75 8278.75 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 347 423.25 15660.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 882 4167.75 154179.00 36.99
Subtotal (Total Children Is Unduplicated) 886 4814.75 178118.00 36.99
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 2.00 150.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 2.00 150.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 7.00 525.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 13 13.50 1012.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.50 83.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 13 13.00 975.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 15 15.00 607.50 40.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 22 55.00 3551.75 64.58
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 2.00 100.00 50.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 75.00 25.00 0.33
Subtotal (Total Children Is Unduplicated) 1 77.00 125.00 1.62
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Total 4946.75 181794.75 36.75
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Number of Children (Unduplicated) With at Least One Service 886
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Center 51
Flag Claims Units Chgs Paid
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R 19 20.00 740.00 0.00
U 0 0.00 0.00 0.00
B 3695 2663.75 99376.00 0.00
P 1 75.00 25.00 25.00
D 14 12.25 463.75 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
3305 2175.00 81162.25 0.00
Other 1 0.75 27.75 0.00
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Total 7035 4946.75 181794.75 25.00