CMS/EIP Fiscal Report Center: 09
Services beginning 07/01/2009 ending 09/30/2009 Date of Report:11/16/2009 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 704 1901.75 70364.75 37.00
Subtotal (Total Children Is Unduplicated) 704 1901.75 70364.75 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 28 46.50 3487.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 5.00 375.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 9 11.00 825.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 12 23.50 1762.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 8 14.00 777.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 117 176.00 13200.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 25 42.50 3187.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 61 79.50 5962.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 90 152.00 8436.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 17.50 1312.50 75.00
Subtotal (Total Children Is Unduplicated) 201 567.50 39325.50 69.30
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 59 317.50 15875.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 32 154.25 10470.49 67.88
PHY-97110-PT SESSION BY LICENSED PT 21 99.50 6754.06 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 15.75 1069.11 67.88
Subtotal (Total Children Is Unduplicated) 105 587.00 34168.66 58.21
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Total 3056.25 143858.91 47.07
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Number of Children (Unduplicated) With at Least One Service 772
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Center 09
Flag Claims Units Chgs Paid
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R 13 12.00 444.00 27.75
U 0 0.00 0.00 0.00
B 938 874.50 44230.89 335.00
P 2489 2146.00 98192.27 98132.52
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 1 0.50 18.50 18.50
T 0 0.00 0.00 0.00
28 23.25 973.25 0.00
Other 0 0.00 0.00 0.00
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Total 3469 3056.25 143858.91 98513.77