CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2010 ending 09/30/2010 Date of Report:11/17/2010 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 422 1185.250000 43678.5000 36.8517
Subtotal (Total Children Is Unduplicated) 422 1185.250000 43678.5000 36.8517
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 8 16.000000 1200.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.000000 225.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 11 21.000000 1129.5000 53.7857
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 18 36.000000 2700.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 72 142.000000 7881.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 54 107.500000 8062.5000 75.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 4 5.000000 242.5000 48.5000
Subtotal (Total Children Is Unduplicated) 88 330.500000 21440.5000 64.8729
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 3 3.000000 75.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 70 218.000000 10802.0000 49.5505
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 3 3.000000 150.0000 50.0000
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 1.000000 50.0000 50.0000
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 1 1.000000 50.0000 50.0000
Subtotal (Total Children Is Unduplicated) 77 226.000000 11127.0000 49.2345
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Total 1741.750000 76246.0000 43.7755
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Number of Children (Unduplicated) With at Least One Service 444
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Center 53
Flag Claims Units Chgs Paid
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R 80 83.250000 3321.2500 311.0000
U 0 0.000000 0.0000 0.0000
B 1139 1052.500000 43377.0000 0.0000
P 533 589.750000 28981.5000 28194.0000
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
14 16.250000 566.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1766 1741.750000 76246.0000 28505.0000