CMS/EIP Fiscal Report Center: 09
Services beginning 01/01/2010 ending 03/31/2010 Date of Report:05/17/2010 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 2 1.00 37.00 37.00
Subtotal (Total Children Is Unduplicated) 2 1.00 37.00 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 23 41.50 3112.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.00 225.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 21 39.00 2925.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 5.50 305.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 69 89.50 6712.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 5.00 375.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 12 15.50 1162.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 48 62.00 3441.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 45 60.50 4537.50 75.00
Subtotal (Total Children Is Unduplicated) 127 321.50 22796.25 70.91
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 4.50 225.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 1 4.00 271.52 67.88
PHY-97110-PT SESSION BY LICENSED PT 3 16.50 1120.02 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 7 32.00 2172.16 67.88
Subtotal (Total Children Is Unduplicated) 12 57.00 3788.70 66.47
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Total 379.50 26621.95 70.15
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Number of Children (Unduplicated) With at Least One Service 138
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Center 09
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 0 0.00 0.00 0.00
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
287 379.50 26621.95 0.00
Other 0 0.00 0.00 0.00
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Total 287 379.50 26621.95 0.00