CMS/EIP Fiscal Report Center: 52
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 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 411 1236.25 45426.75 36.75
Subtotal (Total Children Is Unduplicated) 411 1236.25 45426.75 36.75
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 3.50 262.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.00 48.50 48.50
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.00 225.00 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 58 90.50 6708.00 74.12
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 4.00 300.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 31 39.50 2883.00 72.99
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 69 106.50 5910.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 15 24.00 1800.00 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 23 24.00 1164.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 8 8.00 388.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 7 7.00 350.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 17 17.00 824.50 48.50
Subtotal (Total Children Is Unduplicated) 148 330.50 21003.00 63.55
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.00 519.95 519.95
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 75 390.00 19500.00 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 1 10.00 500.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 56 359.75 24419.83 67.88
OCCT-97530HM-OT SESSION BY OT ASST 1 1.50 81.48 54.32
PHY-97110-PT SESSION BY LICENSED PT 60 319.25 21670.69 67.88
PHY-97110HM-PT SESSION BY PT ASST 1 1.50 81.48 54.32
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 2 5.00 250.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 116 524.25 35565.75 67.84
SPL-92508-GROUP SPL SESSION PER CHILD 2 10.50 138.60 13.20
Subtotal (Total Children Is Unduplicated) 211 1622.75 102727.78 63.30
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Total 3189.50 169157.53 53.04
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Number of Children (Unduplicated) With at Least One Service 433
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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 2502 1775.25 78776.79 0.00
P 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 19 20.50 1066.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
620 1393.75 89314.49 0.00
Other 0 0.00 0.00 0.00
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Total 3141 3189.50 169157.53 0.00