CMS/EIP Fiscal Report Center: 53
Services beginning 01/01/2010 ending 03/31/2010 Date of Report:05/17/2010 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 270 602.00 22274.00 37.00
Subtotal (Total Children Is Unduplicated) 270 602.00 22274.00 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.00 300.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 5.00 375.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 6.00 333.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 20 38.50 2887.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 17 33.00 2475.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 84 161.50 8963.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 60 123.00 9225.00 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 3.00 145.50 48.50
Subtotal (Total Children Is Unduplicated) 101 374.00 24704.25 66.05
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 3 3.00 75.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 63 144.50 7225.00 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 5 9.00 450.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 5 9.00 610.92 67.88
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 6 6.00 300.00 50.00
Subtotal (Total Children Is Unduplicated) 79 171.50 8660.92 50.50
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Total 1147.50 55639.17 48.49
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Number of Children (Unduplicated) With at Least One Service 335
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Center 53
Flag Claims Units Chgs Paid
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R 47 85.00 4640.00 0.00
U 0 0.00 0.00 0.00
B 288 301.00 13655.25 0.00
P 718 754.75 37081.17 37080.92
D 0 0.00 0.00 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
9 5.75 212.75 0.00
Other 1 1.00 50.00 0.00
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Total 1063 1147.50 55639.17 37080.92