CMS/EIP Fiscal Report Center: 54
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 718 2201.00 81187.25 36.89
Subtotal (Total Children Is Unduplicated) 718 2201.00 81187.25 36.89
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 6 7.50 562.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 6 9.50 712.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 12 17.00 943.50 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 8 11.50 862.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 21 36.00 1998.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 37 58.50 4387.50 75.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 3 3.00 145.50 48.50
Subtotal (Total Children Is Unduplicated) 69 145.00 9762.00 67.32
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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 104 613.25 30650.00 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 14 87.25 5922.53 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 1 4.00 52.80 13.20
Subtotal (Total Children Is Unduplicated) 111 711.00 36970.03 52.00
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Total 3057.00 127919.28 41.84
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Number of Children (Unduplicated) With at Least One Service 731
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Center 54
Flag Claims Units Chgs Paid
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R 68 65.00 2854.50 0.00
U 0 0.00 0.00 0.00
B 1842 1443.75 60635.18 0.00
P 2080 1495.50 61825.36 61787.48
D 40 28.50 1463.48 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
29 24.25 1140.76 0.00
Other 0 0.00 0.00 0.00
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Total 4059 3057.00 127919.28 61787.48