CMS/EIP Fiscal Report Center: 54
Services beginning 01/01/2010 ending 03/31/2010 Date of Report:05/17/2010 Page: 1
Payclass Filters:GR
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 74 272.25 10027.00 36.83
Subtotal (Total Children Is Unduplicated) 158 449.00 16566.75 36.90
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-TRANSITION ASSESSMENT 1 2.00 100.00 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 4 8.00 600.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.00 150.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 4.50 249.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 8.00 600.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 9.00 675.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 17 27.00 1498.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 5.00 375.00 75.00
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 31 68.00 4380.00 64.41
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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 2 18.00 900.00 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 11810.8 10200.19 0.86
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Total 12327.75 31146.94 2.53
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Number of Children (Unduplicated) With at Least One Service 170
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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 0 0.00 0.00 0.00
P 169 7932.25 11264.94 11264.94
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
595 4386.25 19539.75 0.00
Other 0 0.00 0.00 0.00
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Total 772 12327.75 31146.94 11264.94