CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2010 ending 03/31/2010 Date of Report:05/17/2010 Page: 1
Payclass Filters:TPIN
Eligibility Filter:DEI Only
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.00 75.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 4.44 333.28 75.06
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 5.50 412.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 1.50 83.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 8.00 600.00 75.00
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 1 1.00 50.15 50.15
Subtotal (Total Children Is Unduplicated) 15 22.44 1629.18 72.60
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 2.00 100.00 50.00
Subtotal (Total Children Is Unduplicated) 1 2.00 100.00 50.00
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Total 24.44 1729.18 70.75
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Number of Children (Unduplicated) With at Least One Service 16
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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 0 0.00 0.00 0.00
D 10 8.50 608.25 0.00
S 0 0.00 0.00 0.00
H 1 1.00 75.00 0.00
T 0 0.00 0.00 0.00
0 0.00 0.00 0.00
Other 14 11.00 825.00 0.00
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Total 25 20.50 1508.25 0.00
Center 05
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 8.50 608.25 0.00
S 0 0.00 0.00 0.00
H 0 1.00 75.00 0.00
T 0 0.00 0.00 0.00
1 1.00 50.15 0.00
Other 0 11.00 825.00 0.00
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Total 1 21.50 1558.40 0.00
Center 06
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 8.50 608.25 0.00
S 0 0.00 0.00 0.00
H 0 1.00 75.00 0.00
T 0 0.00 0.00 0.00
2 3.00 150.15 0.00
Other 0 11.00 825.00 0.00
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Total 2 23.50 1658.40 0.00
Center 55
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 8.50 608.25 0.00
S 0 0.00 0.00 0.00
H 0 1.00 75.00 0.00
T 0 0.00 0.00 0.00
1 3.94 220.93 0.00
Other 0 11.00 825.00 0.00
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Total 1 24.44 1729.18 0.00