CMS/EIP Fiscal Report Center: 04
Services beginning 04/01/2010 ending 06/30/2010 Date of Report:08/18/2010 Page: 1
Agency Filter:EIP DEI DEIP
Payclass Filters:GR
Eligibility Filter:Part C (excluding not eligible)
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 593 435.25 16104.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 403 412.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 24 15.25 564.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 485 1615.25 59764.25 37.00
Subtotal (Total Children Is Unduplicated) 1047 2477.75 76432.75 30.85
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 44 43.00 2150.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 61 53.50 2675.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 2.50 187.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 3.50 262.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 5.00 375.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 37 31.50 2362.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 9 8.50 471.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 23 13.00 975.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 29 22.50 1687.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 67 65.00 3607.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 145 126.00 9450.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 8 8.00 1480.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.00 275.00 275.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.00 105.00 105.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 13 13.00 630.50 48.50
Subtotal (Total Children Is Unduplicated) 346 397.00 26694.75 67.24
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 1 1.00 73.42 73.42
TRAN-TRAN-FAMILY TRANSPORTATION 321 327.00 2616.00 8.00
Subtotal (Total Children Is Unduplicated) 321 328.00 2689.42 8.20
----------------------------------------------------------------------------------------------------------------
Total 3202.75 105816.92 33.04
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1070
----------------------------------------------------------------------------------------------------------------
Center 04
Flag Claims Units Chgs Paid
-------------------------------------------------
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 0 0.00 0.00 0.00
D 69 67.00 2479.00 2479.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
3669 3135.75 103337.92 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 3738 3202.75 105816.92 2479.00