CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2009 ending 09/30/2009 Date of Report:11/17/2009 Page: 1
Payclass Filters:MED
Bill Flag Filter:RBPU
Eligibility Filter:All
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 337 833.25 30830.25 37.00
Subtotal (Total Children Is Unduplicated) 337 833.25 30830.25 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.00 150.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.50 112.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.00 150.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 6.00 333.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 46 89.29 6696.77 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 15 25.79 1934.27 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 95 183.00 10156.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 41 74.50 5587.50 75.00
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 1.00 50.00 50.00
Subtotal (Total Children Is Unduplicated) 115 385.08 25170.54 65.36
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 9 10.00 250.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 114 495.50 24775.00 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 5 8.00 400.00 50.00
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 7 13.00 650.00 50.00
Subtotal (Total Children Is Unduplicated) 125 526.50 26075.00 49.53
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Total 1744.83 82075.79 47.04
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Number of Children (Unduplicated) With at Least One Service 412
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Center 53
Flag Claims Units Chgs Paid
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R 18 19.75 1016.50 0.00
U 0 0.00 0.00 0.00
B 582 515.00 20613.00 0.00
P 1141 1210.08 60446.29 60390.79
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
0 0.00 0.00 0.00
Other 0 0.00 0.00 0.00
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Total 1741 1744.83 82075.79 60390.79