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
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 322 223.75 8278.75 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 347 423.25 15660.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 359 1511.25 55907.00 36.99
Subtotal (Total Children Is Unduplicated) 687 2158.25 79846.00 37.00
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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-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 8.00 600.00 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 5.00 375.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 10 10.00 405.00 40.50
Subtotal (Total Children Is Unduplicated) 12 27.00 1680.00 62.22
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EI Services,Class #03
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 75.00 25.00 0.33
Subtotal (Total Children Is Unduplicated) 1 75.00 25.00 0.33
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Total 2260.25 81551.00 36.08
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Number of Children (Unduplicated) With at Least One Service 688
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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 0 0.00 0.00 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
3304 2173.00 81062.25 0.00
Other 0 0.00 0.00 0.00
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Total 3319 2260.25 81551.00 25.00