CMS/EIP Fiscal Report Center: 53
Services beginning 04/01/2010 ending 06/30/2010 Date of Report:08/18/2010 Page: 1
Payclass Filters:MED
Eligibility Filter:DEI Only
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 12 35.75 1276.50 35.71
Subtotal (Total Children Is Unduplicated) 12 35.75 1276.50 35.71
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 6.00 450.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.00 222.00 55.50
Subtotal (Total Children Is Unduplicated) 4 10.00 672.00 67.20
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 5 19.00 950.00 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 1 8.00 400.00 50.00
PHY-97110-PT SESSION BY LICENSED PT 1 0.75 50.91 67.88
Subtotal (Total Children Is Unduplicated) 7 27.75 1400.91 50.48
----------------------------------------------------------------------------------------------------------------
Total 73.50 3349.41 45.57
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 14
----------------------------------------------------------------------------------------------------------------
Center 53
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 41 35.00 1311.75 0.00
P 13 17.75 986.75 986.75
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
21 20.75 1050.91 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 75 73.50 3349.41 986.75