CMS/EIP Fiscal Report Center: 57
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 444 989.75 36620.75 37.00
Subtotal (Total Children Is Unduplicated) 444 989.75 36620.75 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 2 2.50 138.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 52 62.50 4687.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 52 78.50 4356.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 3.50 262.50 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 4 4.00 194.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 4 4.00 194.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 6 6.00 291.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 17 17.00 824.50 48.50
Subtotal (Total Children Is Unduplicated) 81 182.00 11249.00 61.81
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 361 2753.00 137570.00 49.97
OCCT-97530-OT SESSION BY LICENSED OT 30 142.00 9638.96 67.88
PHY-97110-PT SESSION BY LICENSED PT 37 160.00 10860.80 67.88
PHY-97110HM-PT SESSION BY PT ASST 1 1.00 54.32 54.32
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 2 2.00 100.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 52 195.25 13235.69 67.79
Subtotal (Total Children Is Unduplicated) 410 3253.25 171459.77 52.70
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Total 4425.00 219329.52 49.57
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Number of Children (Unduplicated) With at Least One Service 629
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Center 57
Flag Claims Units Chgs Paid
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R 182 180.25 6754.00 0.00
U 0 0.00 0.00 0.00
B 941 950.00 39006.50 0.00
P 1 2.00 74.00 74.00
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 4 19.00 950.00 950.00
1082 3273.75 172545.02 146477.63
Other 0 0.00 0.00 0.00
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Total 2210 4425.00 219329.52 147501.63