CMS/EIP Fiscal Report Center: 57
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 Page: 1
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 592 2243.00 82991.00 37.00
Subtotal (Total Children Is Unduplicated) 592 2243.00 82991.00 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 3.00 225.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 4.50 249.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 92 124.00 9300.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 98 151.00 8380.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 7.00 525.00 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 5 5.00 242.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 9 9.00 436.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 15 15.00 727.50 48.50
Subtotal (Total Children Is Unduplicated) 124 319.50 20135.25 63.02
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 355 3119.00 155900.00 49.98
OCCT-97530-OT SESSION BY LICENSED OT 33 85.50 5803.74 67.88
PHY-97110-PT SESSION BY LICENSED PT 38 114.50 7772.26 67.88
PHY-97110HM-PT SESSION BY PT ASST 1 2.50 135.80 54.32
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 2 2.00 100.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 55 139.75 9316.53 66.67
Subtotal (Total Children Is Unduplicated) 409 3463.25 179028.33 51.69
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Total 6025.75 282154.58 46.82
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Number of Children (Unduplicated) With at Least One Service 672
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Center 57
Flag Claims Units Chgs Paid
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R 115 143.75 5488.25 0.00
U 0 0.00 0.00 0.00
B 436 495.00 20250.00 0.00
P 1755 1854.50 73485.25 73485.25
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 11 34.00 1735.76 1735.76
1126 3498.50 181195.32 164327.91
Other 0 0.00 0.00 0.00
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Total 3443 6025.75 282154.58 239548.92