CMS/EIP Fiscal Report Center: 53
Services beginning 04/01/2010 ending 06/30/2010 Date of Report:08/18/2010 Page: 1
Agency Filter:EIP DEI DEIP
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 215 168.75 6243.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 362 440.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 414 658.75 24373.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 694 2237.75 82759.75 36.98
TCON-TCON-TRANSITION CONFERENCE 114 115.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 715 3620.25 113377.25 31.32
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
EXIT-EXIT-TRANSITION ASSESSMENT 69 129.75 6487.50 50.00
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 3 5.00 277.50 55.50
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 8 16.00 1200.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 4.00 300.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 6 11.00 825.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 13 24.00 1332.00 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 58 114.00 6482.14 56.86
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 30 61.50 4728.64 76.89
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 20 42.00 3382.28 80.53
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 17.00 1391.14 81.83
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 118 236.50 13746.31 58.12
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 100 233.50 17860.92 76.49
NUTR-NUTR-UNSPECIFIED NUTRITIONAL EVAL 2 3.00 150.00 50.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 4 4.00 194.00 48.50
Subtotal (Total Children Is Unduplicated) 241 901.25 58357.43 64.75
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 144 200.75 10037.50 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 30 30.50 762.50 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 2 2.50 125.00 50.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 1.00 50.00 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 3.00 150.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 6 12.00 600.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 2 101.00 2525.00 25.00
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 1 1.00 73.42 73.42
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 18 20.00 500.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 121 470.50 23525.00 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 7 19.00 950.00 50.00
INTR-INTR-INTERPRETER 6 7.00 350.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 14 56.00 4277.92 76.39
OCCT-97530HM-OT SESSION BY OT ASST 10 25.00 1358.00 54.32
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 12 101.00 5050.00 50.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 406 45085.0 22503.50 0.50
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 1 3.00 150.00 50.00
Subtotal (Total Children Is Unduplicated) 436 46138.3 72987.84 1.58
----------------------------------------------------------------------------------------------------------------
Total 50659.75 244722.52 4.83
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 739
----------------------------------------------------------------------------------------------------------------
Center 53
Flag Claims Units Chgs Paid
-------------------------------------------------
R 7 6.50 240.50 0.00
U 0 0.00 0.00 0.00
B 1584 1370.75 56004.71 0.00
P 1078 9750.25 59229.03 58341.53
D 4 7.00 335.00 185.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 1 0.75 27.75 0.00
4049 39524.50 128885.53 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 6723 50659.75 244722.52 58526.53