CMS/EIP Fiscal Report Center: 01
Services beginning 04/01/2010 ending 06/30/2010 Date of Report:08/18/2010 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 88 40.25 1489.25 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 140 154.00 5698.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 104 400.25 14809.25 37.00
Subtotal (Total Children Is Unduplicated) 197 594.50 21996.50 37.00
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 15 18.00 1350.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 2.00 150.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 3.00 225.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 12 16.00 888.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 3.50 262.50 75.00
Subtotal (Total Children Is Unduplicated) 16 42.50 2875.50 67.66
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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 3.25 149.45 45.98
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 21 1557.00 778.50 0.50
Subtotal (Total Children Is Unduplicated) 23 1580.75 1692.95 1.07
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Total 2217.75 26564.95 11.98
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Number of Children (Unduplicated) With at Least One Service 201
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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 0 0.00 0.00 0.00
P 22 926.25 707.50 707.50
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 13 404.50 444.50 444.50
T 20 132.00 481.95 481.95
855 613.00 23218.25 0.00
Other 25 142.00 1712.75 0.00
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Total 935 2217.75 26564.95 1633.95