CMS/EIP Fiscal Report Center: 01
Services beginning 04/01/2010 ending 06/30/2010 Date of Report:08/18/2010 Page: 1
Payclass Filters:MED
Eligibility Filter:DEI Only
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 155 340.00 12580.00 37.00
Subtotal (Total Children Is Unduplicated) 155 340.00 12580.00 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 2.00 150.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.00 166.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 15 18.50 1387.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.50 112.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 3.00 225.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 12 15.00 832.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 1.00 75.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 20 45.00 2997.50 66.61
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 13 68.00 3400.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 1 5.00 339.40 67.88
PHY-97110-PT SESSION BY LICENSED PT 1 12.00 814.56 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 4.00 271.52 67.88
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 0.50 27.16 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 1 4.00 52.80 13.20
Subtotal (Total Children Is Unduplicated) 17 93.50 4905.44 52.46
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Total 478.50 20482.94 42.81
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Number of Children (Unduplicated) With at Least One Service 157
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Center 01
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 301 213.00 8283.25 0.00
P 123 93.00 3505.75 3505.75
D 3 1.25 46.25 0.00
S 75 54.75 2120.75 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
29 75.00 3933.68 0.00
Other 42 41.50 2593.26 0.00
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Total 573 478.50 20482.94 3505.75