CMS/EIP Fiscal Report Center: 54
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 31 10.25 379.25 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 125 166.50 6160.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 185 763.25 28064.50 36.77
Subtotal (Total Children Is Unduplicated) 185 940.00 34604.25 36.81
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-TRANSITION ASSESSMENT 2 3.50 175.00 50.00
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 1 1.50 83.25 55.50
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 10.00 750.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 6 7.50 562.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 8.00 600.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 5.50 305.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 7 10.50 787.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 35 48.50 3637.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 39 63.00 3496.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 45 69.50 5212.50 75.00
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 93 228.50 15658.50 68.53
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EI Services,Class #03
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 1.00 50.00 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 2.00 100.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 5 35.50 1775.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 1 11.75 797.59 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 114 11776.0 8252.60 0.70
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 1 2.00 100.00 50.00
Subtotal (Total Children Is Unduplicated) 114 11828.3 11075.19 0.94
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Total 12996.75 61337.94 4.72
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Number of Children (Unduplicated) With at Least One Service 185
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Center 54
Flag Claims Units Chgs Paid
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R 8 9.25 342.25 0.00
U 0 0.00 0.00 0.00
B 631 581.00 24895.25 0.00
P 188 7946.25 11782.94 11782.94
D 1 1.00 37.00 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
648 4459.25 24280.50 0.00
Other 0 0.00 0.00 0.00
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Total 1476 12996.75 61337.94 11782.94