CMS/EIP Fiscal Report Center: 52
Services beginning 04/01/2010 ending 06/30/2010 Date of Report:08/18/2010 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 412 1129.75 41791.50 36.99
Subtotal (Total Children Is Unduplicated) 412 1129.75 41791.50 36.99
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 2.50 187.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 6.00 333.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 37 60.00 4500.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 5.50 412.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 10.00 750.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 47 78.50 4356.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 15.00 1125.00 75.00
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 10 10.00 500.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 4 4.00 194.00 48.50
Subtotal (Total Children Is Unduplicated) 77 192.50 12407.25 64.45
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 4.00 100.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 31 137.50 6875.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 2 16.00 1086.08 67.88
PHY-97110-PT SESSION BY LICENSED PT 12 44.00 2986.72 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 18 116.75 7924.99 67.88
Subtotal (Total Children Is Unduplicated) 61 318.25 18972.79 59.62
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Total 1640.50 73171.54 44.60
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Number of Children (Unduplicated) With at Least One Service 418
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Center 52
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 86 76.00 4487.17 0.00
P 2420 1552.50 68134.37 68125.12
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
12 12.00 550.00 0.00
Other 0 0.00 0.00 0.00
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Total 2518 1640.50 73171.54 68125.12