CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2010 ending 09/30/2010 Date of Report:11/17/2010 Page: 1
Payclass Filters:TPIN
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
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 30.000000 1110.0000 37.0000
Subtotal (Total Children Is Unduplicated) 1 30.000000 1110.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 5.500000 412.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 270.6600 135.3300
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 6.000000 570.6600 95.1100
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 1 1.000000 50.1500 50.1500
Subtotal (Total Children Is Unduplicated) 9 18.000000 1566.4700 87.0261
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 9.000000 450.0000 50.0000
Subtotal (Total Children Is Unduplicated) 2 9.000000 450.0000 50.0000
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Total 57.000000 3126.4700 54.8504
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Number of Children (Unduplicated) With at Least One Service 12
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Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 5 4.000000 300.0000 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
0 0.000000 0.0000 0.0000
Other 5 4.000000 300.0000 0.0000
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Total 10 8.000000 600.0000 0.0000
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
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
2 3.000000 200.1500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2 3.000000 200.1500 0.0000
Center 06
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
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
11 12.000000 675.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11 12.000000 675.0000 0.0000
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
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
3 34.000000 1651.3200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3 34.000000 1651.3200 0.0000