CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 Page: 1
Agency Filter:EXT
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 1 0.25 9.25 37.00
Subtotal (Total Children Is Unduplicated) 1 0.25 9.25 37.00
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 6.00 333.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 8.50 637.50 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 7 8.00 388.00 48.50
Subtotal (Total Children Is Unduplicated) 17 24.50 1455.50 59.41
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 8.00 353.20 44.15
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.00 30.00 30.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 318 1971.25 98562.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 11 63.25 4293.41 67.88
PHY-97110-PT SESSION BY LICENSED PT 49 276.25 18697.61 67.68
PHY-97110HM-PT SESSION BY PT ASST 9 20.00 1086.40 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 116 440.50 29698.56 67.42
SPL-92508-GROUP SPL SESSION PER CHILD 5 11.00 145.20 13.20
Subtotal (Total Children Is Unduplicated) 444 2791.25 152866.88 54.77
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Total 2816.00 154331.63 54.81
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Number of Children (Unduplicated) With at Least One Service 451
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Center 01
Flag Claims Units Chgs Paid
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R 1 0.25 9.25 0.00
U 0 0.00 0.00 0.00
B 3 3.00 150.00 0.00
P 151 191.50 9575.00 9575.00
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 1 3.00 150.00 200.00
782 1778.25 94560.06 3450.00
Other 549 840.00 49887.32 0.00
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Total 1487 2816.00 154331.63 13225.00