CMS/EIP Fiscal Report Center: 53
Services beginning 04/01/2010 ending 06/30/2010 Date of Report:08/18/2010 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 449 1416.50 52410.50 37.00
Subtotal (Total Children Is Unduplicated) 449 1416.50 52410.50 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 7.00 525.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 3.00 225.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 6 10.00 750.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 10 16.00 888.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 16 31.50 2362.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 15 32.00 2400.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 79 155.50 8630.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 54 115.50 8662.50 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 2.00 97.00 48.50
Subtotal (Total Children Is Unduplicated) 115 372.50 24540.25 65.88
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EI Services,Class #03
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 1 1.00 73.42 73.42
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 14 16.00 400.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 86 304.50 15225.00 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 5 11.00 550.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 7 20.00 1316.92 65.85
OCCT-97530HM-OT SESSION BY OT ASST 8 20.00 1086.40 54.32
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 11 96.00 4800.00 50.00
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 1 3.00 150.00 50.00
Subtotal (Total Children Is Unduplicated) 117 471.50 23601.74 50.06
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Total 2260.50 100552.49 44.48
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Number of Children (Unduplicated) With at Least One Service 482
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Center 53
Flag Claims Units Chgs Paid
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R 7 6.50 240.50 0.00
U 0 0.00 0.00 0.00
B 1584 1370.75 56004.71 0.00
P 706 821.50 41856.53 40969.03
D 1 2.00 150.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 1 0.75 27.75 0.00
64 59.00 2273.00 0.00
Other 0 0.00 0.00 0.00
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Total 2363 2260.50 100552.49 40969.03