CMS/EIP Fiscal Report Center: 52
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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 404 1207.25 44594.25 36.94
Subtotal (Total Children Is Unduplicated) 404 1207.25 44594.25 36.94
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.50 112.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.00 150.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 4.50 249.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 11 17.00 1275.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 7.00 525.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 31 47.50 2636.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 10.50 787.50 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 6 6.00 291.00 48.50
Subtotal (Total Children Is Unduplicated) 49 97.00 6075.50 62.63
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 33 109.25 5462.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 3 27.75 1883.67 67.88
OCCT-97530HM-OT SESSION BY OT ASST 1 1.50 81.48 54.32
PHY-97110-PT SESSION BY LICENSED PT 8 22.75 1544.27 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 28 118.25 8026.81 67.88
Subtotal (Total Children Is Unduplicated) 66 279.50 16998.73 60.82
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Total 1583.75 67668.48 42.73
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Number of Children (Unduplicated) With at Least One Service 411
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Center 52
Flag Claims Units Chgs Paid
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R 234 178.00 9026.76 0.00
U 0 0.00 0.00 0.00
B 953 633.75 29372.97 0.00
P 1311 772.00 29268.75 29268.75
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 2498 1583.75 67668.48 29268.75