CMS/EIP Fiscal Report Center: 01
Services beginning 01/01/2010 ending 03/31/2010 Date of Report:05/17/2010 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 142 522.25 19230.75 36.82
Subtotal (Total Children Is Unduplicated) 142 522.25 19230.75 36.82
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.00 75.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.00 150.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.00 111.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 63 75.50 5662.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 9.50 712.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 11.50 862.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 62 78.00 4329.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 23 33.50 2512.50 75.00
Subtotal (Total Children Is Unduplicated) 81 214.00 14490.00 67.71
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 24.00 1200.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 20.50 1391.54 67.88
Subtotal (Total Children Is Unduplicated) 1 44.50 2591.54 58.24
----------------------------------------------------------------------------------------------------------------
Total 780.75 36312.29 46.51
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 144
----------------------------------------------------------------------------------------------------------------
Center 01
Flag Claims Units Chgs Paid
-------------------------------------------------
R 7 2.75 101.75 0.00
U 0 0.00 0.00 0.00
B 238 176.25 6859.25 0.00
P 408 330.00 13005.75 13005.75
D 3 1.00 37.00 0.00
S 81 62.75 2321.75 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
8 46.50 2693.29 0.00
Other 128 161.50 11293.50 0.00
-------------------------------------------------
Total 873 780.75 36312.29 13005.75