CMS/EIP Fiscal Report Center: 52
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 Page: 1
Agency Filter:EIP DEI DEIP
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 376 1139.25 42004.25 36.87
Subtotal (Total Children Is Unduplicated) 376 1139.25 42004.25 36.87
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 2.50 187.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.00 225.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 3.50 194.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 12 19.00 1425.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 3.50 262.50 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 32 51.00 2830.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 15.50 1162.50 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 5 5.00 250.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 6 6.00 291.00 48.50
Subtotal (Total Children Is Unduplicated) 60 117.00 7401.75 63.26
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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 1535.75 66404.73 43.24
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Number of Children (Unduplicated) With at Least One Service 381
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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 880 565.00 26349.47 0.00
P 1202 684.00 25702.00 25702.00
D 0 0.00 0.00 0.00
S 67 52.25 1859.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
51 56.50 3467.25 0.00
Other 0 0.00 0.00 0.00
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Total 2434 1535.75 66404.73 25702.00