CMS/EIP Fiscal Report Center: 01
Services beginning 04/01/2010 ending 06/30/2010 Date of Report:08/18/2010 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 88 40.25 1489.25 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 140 154.00 5698.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 240 923.25 34132.50 36.97
Subtotal (Total Children Is Unduplicated) 240 1117.50 41319.75 36.98
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 9.50 712.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.00 150.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.50 262.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 6.50 360.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 136 187.50 14062.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 14 17.00 1275.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 18 29.50 2212.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 119 157.00 8713.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 56 76.50 5700.00 74.51
Subtotal (Total Children Is Unduplicated) 175 489.00 33448.75 68.40
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EI Services,Class #03
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 0.50 25.00 50.00
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 7.00 350.00 50.00
INTR-INTR-INTERPRETER 8 13.00 390.00 30.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 14.00 950.32 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 21 1557.00 778.50 0.50
Subtotal (Total Children Is Unduplicated) 23 1591.50 2493.82 1.57
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Total 3198.00 77262.32 24.16
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Number of Children (Unduplicated) With at Least One Service 240
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Center 01
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 448 391.00 17331.75 0.00
P 230 1089.25 6849.50 6849.50
D 46 60.50 3514.25 0.00
S 131 123.75 6070.50 0.00
H 16 409.00 782.00 444.50
T 20 132.00 481.95 481.95
864 619.00 23676.09 0.00
Other 189 373.50 18556.28 0.00
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Total 1944 3198.00 77262.32 7775.95