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: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 1279.75 47202.75 36.88
Subtotal (Total Children Is Unduplicated) 411 1279.75 47202.75 36.88
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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-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.00 150.00 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 4 5.50 305.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 44 63.50 4762.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 12.50 937.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 19 26.50 1987.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 47 73.50 4079.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 15 23.50 1762.50 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 9 9.00 450.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 26 26.00 1261.00 48.50
Subtotal (Total Children Is Unduplicated) 122 261.50 16787.00 64.20
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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
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Total 3132.09 165461.71 52.83
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Number of Children (Unduplicated) With at Least One Service 425
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Center 52
Flag Claims Units Chgs Paid
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R 234 178.00 9026.76 0.00
U 0 0.00 0.00 0.00
B 953 633.75 29372.97 0.00
P 1311 772.00 29268.75 29268.75
D 0 0.00 0.00 0.00
S 82 62.25 2229.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
654 1486.09 95563.98 0.00
Other 0 0.00 0.00 0.00
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Total 3234 3132.09 165461.71 29268.75