CMS/EIP Fiscal Report Center: 57
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 709 2623.50 97069.50 37.00
Subtotal (Total Children Is Unduplicated) 709 2623.50 97069.50 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 5.50 412.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 7 11.00 610.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 90 106.00 7950.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 130 198.00 10989.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.00 225.00 75.00
Subtotal (Total Children Is Unduplicated) 139 323.50 20187.00 62.40
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 4.00 200.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 5.00 339.40 67.88
Subtotal (Total Children Is Unduplicated) 2 9.00 539.40 59.93
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Total 2956.00 117795.90 39.85
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Number of Children (Unduplicated) With at Least One Service 718
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Center 57
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 2633 2719.50 104895.90 0.00
P 157 225.75 12450.25 12450.25
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
8 10.75 449.75 200.00
Other 0 0.00 0.00 0.00
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Total 2798 2956.00 117795.90 12650.25