CMS/EIP Fiscal Report Center: 52
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Payclass Filters:MED
Eligibility Filter:Program Patients
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 351 1077.25 39654.75 36.81
Subtotal (Total Children Is Unduplicated) 351 1077.25 39654.75 36.81
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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 2 2.50 138.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 38 56.50 4237.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 4.50 337.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 13 17.00 1248.50 73.44
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 78 112.50 6243.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 13.50 1012.50 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 4 4.00 194.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 14 16.00 776.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 2 2.00 97.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 7 7.00 339.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 2 2.00 100.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 13 13.00 630.50 48.50
Subtotal (Total Children Is Unduplicated) 130 253.00 15543.00 61.43
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 47 263.25 13162.50 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 1 9.00 450.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 47 317.25 21534.93 67.88
PHY-97110-PT SESSION BY LICENSED PT 48 296.25 20109.45 67.88
PHY-97110HM-PT SESSION BY PT ASST 2 5.75 312.34 54.32
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 2.50 125.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 84 457.21 31034.25 67.88
Subtotal (Total Children Is Unduplicated) 150 1351.21 86728.47 64.19
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Total 2681.46 141926.22 52.93
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Number of Children (Unduplicated) With at Least One Service 360
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Center 52
Flag Claims Units Chgs Paid
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R 8 8.00 534.34 0.00
U 0 0.00 0.00 0.00
B 1351 851.50 35426.92 9.25
P 833 543.00 23990.71 23990.71
D 0 0.00 0.00 0.00
S 3 9.50 351.50 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
562 1269.46 81622.75 0.00
Other 0 0.00 0.00 0.00
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Total 2757 2681.46 141926.22 23999.96