CMS/EIP Fiscal Report Center: 04
Services beginning 04/01/2010 ending 06/30/2010 Date of Report:08/18/2010 Page: 1
Eligibility Filter:DEI Only
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 46 35.00 1295.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 13 13.00 0.00 0.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 91 297.25 10998.25 37.00
Subtotal (Total Children Is Unduplicated) 92 345.25 12293.25 35.61
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 8 7.00 350.00 50.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 2.50 187.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.00 55.50 55.50
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 2.50 138.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 3.00 225.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 5 5.00 925.00 185.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 2 2.00 210.00 105.00
Subtotal (Total Children Is Unduplicated) 14 23.00 2091.75 90.95
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 22.00 1100.00 50.00
TRAN-TRAN-FAMILY TRANSPORTATION 7 7.00 56.00 8.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 3 312.00 156.00 0.50
Subtotal (Total Children Is Unduplicated) 9 341.00 1312.00 3.85
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Total 709.25 15697.00 22.13
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Number of Children (Unduplicated) With at Least One Service 92
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Center 04
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 117 73.75 2785.25 0.00
P 194 441.50 5592.75 5042.81
D 14 8.50 314.50 314.50
S 0 0.00 0.00 0.00
H 6 22.00 1100.00 1100.00
T 0 0.00 0.00 0.00
345 163.50 5904.50 0.00
Other 0 0.00 0.00 0.00
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Total 676 709.25 15697.00 6457.31