CMS/EIP Fiscal Report Center: 52
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 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 353 1032.75 37897.25 36.70
Subtotal (Total Children Is Unduplicated) 353 1032.75 37897.25 36.70
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.50 112.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.00 55.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 37 62.50 4687.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 10 16.00 1200.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 46 75.00 4162.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 16.00 1200.00 75.00
SCREEN-T1023-INTERDISCIPLINARY SCREENING 2 2.00 100.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 3 3.00 145.50 48.50
Subtotal (Total Children Is Unduplicated) 66 177.00 11663.50 65.90
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.00 519.95 519.95
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 41 174.75 8737.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 3 19.50 1323.66 67.88
PHY-97110-PT SESSION BY LICENSED PT 6 18.75 1272.75 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 19 101.00 6855.88 67.88
Subtotal (Total Children Is Unduplicated) 67 315.00 18709.74 59.40
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Total 1524.75 68270.49 44.77
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Number of Children (Unduplicated) With at Least One Service 363
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Center 52
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 2181 1501.75 66621.29 0.00
P 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 18 19.50 1010.75 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
5 3.50 638.45 0.00
Other 0 0.00 0.00 0.00
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Total 2204 1524.75 68270.49 0.00