CMS/EIP Fiscal Report Center: 52
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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 376 1139.25 42004.25 36.87
Subtotal (Total Children Is Unduplicated) 376 1139.25 42004.25 36.87
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 2.50 187.50 75.00
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 3 3.50 194.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 31 45.00 3375.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 11.00 825.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 13 17.50 1312.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 32 51.00 2830.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 19.00 1425.00 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 6 6.00 291.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 8 8.00 388.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 5 5.00 250.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 26 26.00 1261.00 48.50
Subtotal (Total Children Is Unduplicated) 96 197.50 12564.75 63.62
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 64 327.50 16375.00 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 2 16.00 800.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 48 252.00 17105.76 67.88
OCCT-97530HM-OT SESSION BY OT ASST 3 19.50 1059.24 54.32
PHY-97110-PT SESSION BY LICENSED PT 63 292.14 19830.17 67.88
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 6.00 300.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 132 677.70 46001.79 67.88
Subtotal (Total Children Is Unduplicated) 206 1590.84 101471.96 63.79
----------------------------------------------------------------------------------------------------------------
Total 2927.59 156040.96 53.30
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 389
----------------------------------------------------------------------------------------------------------------
Center 52
Flag Claims Units Chgs Paid
-------------------------------------------------
R 234 178.00 9026.76 0.00
U 0 0.00 0.00 0.00
B 880 565.00 26349.47 0.00
P 1202 684.00 25702.00 25702.00
D 0 0.00 0.00 0.00
S 67 52.25 1859.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
627 1448.34 93103.48 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 3010 2927.59 156040.96 25702.00