CMS/EIP Fiscal Report Center: 54
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 804 2525.00 93156.75 36.89
Subtotal (Total Children Is Unduplicated) 804 2525.00 93156.75 36.89
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 8 10.00 750.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 7 11.00 825.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 14 20.50 1137.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.00 150.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 14 17.50 1312.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 40 63.50 3524.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 59 87.50 6562.50 75.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 2 2.00 97.00 48.50
Subtotal (Total Children Is Unduplicated) 101 214.00 14359.00 67.10
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.00 25.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 106 616.25 30800.00 49.98
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 1 3.00 150.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 3 2.50 169.70 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 13 76.75 5209.79 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 1 4.00 52.80 13.20
Subtotal (Total Children Is Unduplicated) 113 703.50 36407.29 51.75
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Total 3442.50 143923.04 41.81
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Number of Children (Unduplicated) With at Least One Service 817
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Center 54
Flag Claims Units Chgs Paid
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R 69 66.00 2904.50 0.00
U 0 0.00 0.00 0.00
B 2099 1661.00 70534.93 0.00
P 2352 1715.50 70483.61 70445.73
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 4520 3442.50 143923.04 70445.73