CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2010 ending 09/30/2010 Date of Report:11/17/2010 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 3 1.000000 37.0000 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 10 12.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 8 38.000000 1406.0000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 14 51.250000 1896.2500 37.0000
Subtotal (Total Children Is Unduplicated) 15 102.250000 3339.2500 32.6577
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 8.500000 637.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 6 10.500000 742.4100 70.7057
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 10.500000 908.1600 86.4914
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.000000 48.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.000000 97.0000 48.5000
Subtotal (Total Children Is Unduplicated) 9 32.500000 2433.5700 74.8791
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.500000 75.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 3 68.000000 1700.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 4.000000 200.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 10 47.000000 2350.0000 50.0000
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 1 12.000000 600.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 2.000000 135.7600 67.8800
PHY-97110-PT SESSION BY LICENSED PT 2 8.000000 543.0400 67.8800
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 14 2775.000000 1387.5000 0.5000
Subtotal (Total Children Is Unduplicated) 14 2917.500000 6991.3000 2.3963
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Total 3052.250000 12764.1200 4.1819
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Number of Children (Unduplicated) With at Least One Service 16
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Center 53
Flag Claims Units Chgs Paid
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R 3 4.000000 148.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 24 33.000000 1405.0000 0.0000
P 33 39.000000 2114.2500 2114.2500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 34 1044.000000 1459.5000 1459.5000
T 28 846.250000 859.0100 859.0100
110 1086.000000 6778.3600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 232 3052.250000 12764.1200 4432.7600