CMS/EIP Fiscal Report Center: 54
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 746 2526.50 93175.25 36.88
Subtotal (Total Children Is Unduplicated) 746 2526.50 93175.25 36.88
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 11 16.00 1200.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 14 23.50 1762.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 8.00 444.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 3.50 262.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 22 32.50 2437.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 32 54.50 3024.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 35 56.50 4237.50 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 8 8.00 388.00 48.50
Subtotal (Total Children Is Unduplicated) 93 202.50 13756.75 67.93
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 115 635.25 31737.50 49.96
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 1 3.00 150.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 4 27.00 1832.76 67.88
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 5 5.00 250.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 9 90.50 6143.14 67.88
Subtotal (Total Children Is Unduplicated) 129 760.75 40113.40 52.73
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Total 3489.75 147045.40 42.14
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Number of Children (Unduplicated) With at Least One Service 753
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Center 54
Flag Claims Units Chgs Paid
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R 3 4.50 312.50 0.00
U 0 0.00 0.00 0.00
B 4397 3262.25 135279.71 0.00
P 233 185.75 9890.79 9822.91
D 29 16.50 737.77 0.00
S 2 0.75 27.75 0.00
H 0 0.00 0.00 0.00
T 1 0.25 9.25 0.00
22 18.50 741.38 0.00
Other 2 1.25 46.25 0.00
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Total 4689 3489.75 147045.40 9822.91