CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 Page: 1
Payclass Filters:MED
Eligibility Filter:DEI Only
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 133 294.00 10804.00 36.75
Subtotal (Total Children Is Unduplicated) 133 294.00 10804.00 36.75
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 4.50 337.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.00 222.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 6.00 450.00 75.00
Subtotal (Total Children Is Unduplicated) 4 14.50 1009.50 69.62
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 7 51.00 2550.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 1 8.00 543.04 67.88
PHY-97110-PT SESSION BY LICENSED PT 1 13.00 882.44 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 0.50 33.94 67.88
Subtotal (Total Children Is Unduplicated) 9 72.50 4009.42 55.30
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Total 381.00 15822.92 41.53
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Number of Children (Unduplicated) With at Least One Service 135
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Center 01
Flag Claims Units Chgs Paid
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R 12 7.00 259.00 0.00
U 0 0.00 0.00 0.00
B 250 211.25 7742.25 0.00
P 1 1.00 50.00 50.00
D 10 9.25 513.25 0.00
S 111 70.75 2617.75 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
23 62.25 3406.01 50.00
Other 9 19.50 1234.66 0.00
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Total 416 381.00 15822.92 100.00