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:TPIN
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 3 2.00 74.00 37.00
Subtotal (Total Children Is Unduplicated) 3 2.00 74.00 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.50 194.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 16 25.82 1936.87 75.01
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 2 3.00 225.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 28 45.00 2497.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 6.00 450.00 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 2 2.00 100.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 42 90.82 5763.12 63.46
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EI Services,Class #03
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 1.00 50.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 13 51.50 2575.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 10 34.29 2482.71 72.40
PHY-97110-PT SESSION BY LICENSED PT 4 11.25 763.65 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 19 82.56 5735.92 69.48
Subtotal (Total Children Is Unduplicated) 42 180.60 11607.28 64.27
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Total 273.42 17444.40 63.80
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Number of Children (Unduplicated) With at Least One Service 82
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Center 52
Flag Claims Units Chgs Paid
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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 5 4.92 623.47 623.47
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 30 57.75 4075.05 0.00
T 0 0.00 0.00 0.00
105 210.75 12745.88 0.00
Other 0 0.00 0.00 0.00
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Total 140 273.42 17444.40 623.47