CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2009 ending 09/30/2009 Date of Report:11/16/2009 Page: 1
Agency Filter:EIP DEI DEIP
Payclass Filters:MED
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
TCM-T1017TL-TARGETED CASE MANAGEMENT 308 753.50 27879.50 37.00
Subtotal (Total Children Is Unduplicated) 308 753.50 27879.50 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.00 150.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.50 112.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.00 150.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 6.00 333.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 41 79.79 5984.27 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 15 25.79 1934.27 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 81 156.00 8658.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 35 63.50 4762.50 75.00
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 1.00 50.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 101 338.58 22183.04 65.52
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 8 9.00 225.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 112 490.50 24525.00 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 5 8.00 400.00 50.00
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 7 13.00 650.00 50.00
Subtotal (Total Children Is Unduplicated) 122 520.50 25800.00 49.57
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Total 1612.58 75862.54 47.04
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Number of Children (Unduplicated) With at Least One Service 382
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Center 53
Flag Claims Units Chgs Paid
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R 18 19.75 1016.50 0.00
U 0 0.00 0.00 0.00
B 537 468.25 18844.25 0.00
P 1070 1115.58 55455.29 55399.79
D 4 6.00 359.50 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
2 3.00 187.00 0.00
Other 0 0.00 0.00 0.00
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Total 1631 1612.58 75862.54 55399.79