CMS/EIP Fiscal Report Center: 57
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 577 2231.25 82556.25 37.00
Subtotal (Total Children Is Unduplicated) 577 2231.25 82556.25 37.00
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 3.00 225.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 4.50 249.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 92 124.00 9300.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 98 151.00 8380.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 7.00 525.00 75.00
Subtotal (Total Children Is Unduplicated) 101 289.50 18680.25 64.53
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 2 2.50 169.70 67.88
PHY-97110-PT SESSION BY LICENSED PT 2 2.50 169.70 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 5 6.50 441.22 67.88
Subtotal (Total Children Is Unduplicated) 5 11.50 780.62 67.88
----------------------------------------------------------------------------------------------------------------
Total 2532.25 102017.12 40.29
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 578
----------------------------------------------------------------------------------------------------------------
Center 57
Flag Claims Units Chgs Paid
-------------------------------------------------
R 115 143.75 5488.25 0.00
U 0 0.00 0.00 0.00
B 435 494.00 20213.00 0.00
P 1734 1843.75 73087.50 73087.50
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
40 50.75 3228.37 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 2324 2532.25 102017.12 73087.50