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: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 2 21.75 804.75 37.00
Subtotal (Total Children Is Unduplicated) 2 21.75 804.75 37.00
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-TRANSITION ASSESSMENT 9 19.75 987.50 50.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 6.00 450.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 4.00 222.00 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 9 14.50 1087.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 12 21.00 1165.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 20.00 1500.00 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 6 6.00 291.00 48.50
Subtotal (Total Children Is Unduplicated) 48 94.75 5966.00 62.97
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 5 6.00 300.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 11 11.00 550.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 2 1.00 25.00 25.00
CONOP-CONOP-CONSULT, OT, PHONE 1 1.00 25.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 51 256.25 12812.50 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 7 15.00 750.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 3 17.00 1153.96 67.88
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 1.00 50.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 15 127.00 8705.61 68.55
SPL-92508-GROUP SPL SESSION PER CHILD 1 0.50 6.60 13.20
Subtotal (Total Children Is Unduplicated) 79 435.75 24378.67 55.95
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Total 552.25 31149.42 56.40
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Number of Children (Unduplicated) With at Least One Service 118
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Center 54
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 0 0.00 0.00 0.00
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
520 552.25 31149.42 0.00
Other 0 0.00 0.00 0.00
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Total 520 552.25 31149.42 0.00