CMS/EIP Fiscal Report Center: 52
Services beginning 04/01/2010 ending 06/30/2010 Date of Report:08/18/2010 Page: 1
Agency Filter:EIP DEI DEIP
Payclass Filters:OTHER
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 1 0.25 9.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 3 1.50 55.50 37.00
Subtotal (Total Children Is Unduplicated) 3 1.75 64.75 37.00
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.50 112.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 3.50 194.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 6.00 450.00 75.00
Subtotal (Total Children Is Unduplicated) 8 12.00 831.75 69.31
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 0.25 12.50 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 0.25 12.50 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 12 6.75 337.50 50.00
PHY-97110-PT SESSION BY LICENSED PT 5 14.75 1001.23 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 6 21.00 1425.48 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 3 90.00 45.00 0.50
Subtotal (Total Children Is Unduplicated) 28 133.00 2834.21 21.31
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Total 146.75 3730.71 25.42
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Number of Children (Unduplicated) With at Least One Service 39
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Center 52
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 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 1 0.25 9.25 0.00
H 21 44.50 3019.97 0.00
T 0 0.00 0.00 0.00
27 102.00 701.49 0.00
Other 0 0.00 0.00 0.00
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Total 49 146.75 3730.71 0.00