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:OTHER
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 4 2.00 74.00 37.00
Subtotal (Total Children Is Unduplicated) 4 2.00 74.00 37.00
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.00 150.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 4.50 337.50 75.00
Subtotal (Total Children Is Unduplicated) 4 6.50 487.50 75.00
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.00 15.00 15.00
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.00 50.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 0.25 12.50 50.00
CONOP-CONOP-CONSULT, OT, PHONE 1 0.50 12.50 25.00
CONSP-CONSP-CONSULT, SLP, PHONE 2 1.00 25.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 7 4.75 237.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 5 19.25 1306.69 67.88
PHY-97110-PT SESSION BY LICENSED PT 2 13.25 899.41 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 9 14.00 950.32 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 2 43.00 21.50 0.50
Subtotal (Total Children Is Unduplicated) 25 98.00 3530.42 36.02
----------------------------------------------------------------------------------------------------------------
Total 106.50 4091.92 38.42
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 32
----------------------------------------------------------------------------------------------------------------
Center 52
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 26 50.75 3418.92 0.00
T 0 0.00 0.00 0.00
24 55.75 673.00 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 50 106.50 4091.92 0.00