CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2010 ending 09/30/2010 Date of Report:11/17/2010 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 13 47.000000 1739.0000 37.0000
Subtotal (Total Children Is Unduplicated) 13 47.000000 1739.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 8.500000 637.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 5 8.500000 471.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 8.500000 637.5000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.000000 48.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 48.5000 48.5000
Subtotal (Total Children Is Unduplicated) 7 27.500000 1843.7500 67.0455
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 9 32.000000 1600.0000 50.0000
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 1 12.000000 600.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 2.000000 135.7600 67.8800
PHY-97110-PT SESSION BY LICENSED PT 1 5.000000 339.4000 67.8800
Subtotal (Total Children Is Unduplicated) 9 51.000000 2675.1600 52.4541
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Total 125.500000 6257.9100 49.8638
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Number of Children (Unduplicated) With at Least One Service 14
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Center 53
Flag Claims Units Chgs Paid
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R 3 4.000000 148.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 24 33.000000 1405.0000 0.0000
P 33 39.000000 2114.2500 2114.2500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
50 49.500000 2590.6600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 110 125.500000 6257.9100 2114.2500