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
Eligibility Filter:Not Part C
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 91 332.00 12265.50 36.94
Subtotal (Total Children Is Unduplicated) 91 332.00 12265.50 36.94
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 4.00 300.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 2.00 150.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 5.00 277.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 4.50 337.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 10 13.00 975.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 26 34.50 1914.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 29 36.50 2737.50 75.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 2 2.00 97.00 48.50
Subtotal (Total Children Is Unduplicated) 48 101.50 6789.25 66.89
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 5.00 250.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 1 1.50 101.82 67.88
Subtotal (Total Children Is Unduplicated) 1 6.50 351.82 54.13
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Total 440.00 19406.57 44.11
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Number of Children (Unduplicated) With at Least One Service 91
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Center 54
Flag Claims Units Chgs Paid
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R 1 1.00 50.00 0.00
U 0 0.00 0.00 0.00
B 238 203.75 9283.25 0.00
P 252 206.75 8155.00 8155.00
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
26 28.50 1918.32 0.00
Other 0 0.00 0.00 0.00
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Total 517 440.00 19406.57 8155.00