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: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 1 1.75 64.75 37.00
Subtotal (Total Children Is Unduplicated) 1 1.75 64.75 37.00
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-TRANSITION ASSESSMENT 1 1.00 50.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.50 187.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 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
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.50 194.25 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 4 8.00 599.14 74.89
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 6.00 566.14 94.36
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 4.00 532.28 133.07
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 9.50 828.64 87.23
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 12 23.50 1924.81 81.91
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 24.00 2148.42 89.52
Subtotal (Total Children Is Unduplicated) 19 84.00 7181.18 85.49
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 9.00 450.00 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 1 3.00 150.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 2 5.00 883.84 176.77
OCCT-97530HM-OT SESSION BY OT ASST 1 1.00 54.32 54.32
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 1.00 50.00 50.00
Subtotal (Total Children Is Unduplicated) 7 19.00 1588.16 83.59
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Total 104.75 8834.09 84.33
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Number of Children (Unduplicated) With at Least One Service 25
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Center 53
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
65 104.75 8834.09 0.00
Other 0 0.00 0.00 0.00
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Total 65 104.75 8834.09 0.00