CMS/EIP Fiscal Report Center: 01
Services beginning 01/01/2010 ending 03/31/2010 Date of Report:05/17/2010 Page: 1
Agency Filter:EIP DEI DEIP
Payclass Filters:TPIN
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 6 5.25 194.25 37.00
Subtotal (Total Children Is Unduplicated) 6 5.25 194.25 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 12 17.00 1275.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.50 262.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 2.00 150.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 13 29.00 2137.50 73.71
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 11.00 610.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 70 94.50 7087.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 21 30.50 2287.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 21 24.00 1800.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 77 111.00 6105.00 55.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 48 70.50 5287.50 75.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 1 2.00 145.56 72.78
Subtotal (Total Children Is Unduplicated) 130 395.00 27148.56 68.73
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 4 9.00 450.00 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.50 75.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 11.00 550.00 50.00
Subtotal (Total Children Is Unduplicated) 8 21.50 1075.00 50.00
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Total 421.75 28417.81 67.38
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Number of Children (Unduplicated) With at Least One Service 142
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Center 01
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 1 1.50 112.50 0.00
D 107 146.50 9045.75 0.00
S 0 0.00 0.00 0.00
H 11 18.50 1220.56 0.00
T 0 0.00 0.00 0.00
12 6.25 269.25 0.00
Other 186 249.00 17769.75 0.00
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Total 317 421.75 28417.81 0.00