CMS/EIP Fiscal Report Center: 09
Services beginning 07/01/2009 ending 09/30/2009 Date of Report:11/17/2009 Page: 1
Agency Filter:EIP DEI DEIP
Payclass Filters:TPIN
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 1 0.75 27.75 37.00
Subtotal (Total Children Is Unduplicated) 1 0.75 27.75 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 26 47.00 3451.00 73.43
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 8 12.00 900.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 6 7.00 525.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 19 39.00 2925.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 7.00 388.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 64 90.50 6787.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 15 25.00 1875.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 42 49.00 3675.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 24 34.50 1914.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 41 64.50 4837.50 75.00
Subtotal (Total Children Is Unduplicated) 134 375.50 27279.25 72.65
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 17 65.00 4412.20 67.88
PHY-97110-PT SESSION BY LICENSED PT 6 33.00 2240.04 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 6 27.50 1866.70 67.88
Subtotal (Total Children Is Unduplicated) 29 125.50 8518.94 67.88
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Total 501.75 35825.94 71.40
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Number of Children (Unduplicated) With at Least One Service 164
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Center 09
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 0 0.00 0.00 0.00
P 0 0.00 0.00 0.00
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
378 501.75 35825.94 0.00
Other 0 0.00 0.00 0.00
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Total 378 501.75 35825.94 0.00