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: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 44 18.75 693.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 82 82.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 2 1.00 37.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 122 522.25 19323.25 37.00
Subtotal (Total Children Is Unduplicated) 123 624.00 20054.00 32.14
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 0.50 37.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 0.50 37.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.50 112.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 2.00 111.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 20 10.50 787.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.00 75.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 25 17.50 1312.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 57 49.50 2747.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 44 43.50 3262.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 35 35.00 6475.00 185.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 2 2.00 97.00 48.50
Subtotal (Total Children Is Unduplicated) 82 163.50 15055.25 92.08
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EI Services,Class #03
TRAN-TRAN-FAMILY TRANSPORTATION 59 62.00 496.00 8.00
Subtotal (Total Children Is Unduplicated) 59 62.00 496.00 8.00
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Total 849.50 35605.25 41.91
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Number of Children (Unduplicated) With at Least One Service 123
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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 115 179.75 7556.50 0.00
P 132 171.00 8723.25 8222.66
D 1 3.00 111.00 111.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
478 495.75 19214.50 0.00
Other 0 0.00 0.00 0.00
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Total 726 849.50 35605.25 8333.66