CMS/EIP Fiscal Report Center: 57
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 Page: 1
Agency Filter:EXT
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 47 45.75 1692.75 37.00
Subtotal (Total Children Is Unduplicated) 47 45.75 1692.75 37.00
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.00 75.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.00 75.00 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) 29 33.00 1653.50 50.11
----------------------------------------------------------------------------------------------------------------
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
----------------------------------------------------------------------------------------------------------------
Total 3332.00 174806.02 52.46
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 438
----------------------------------------------------------------------------------------------------------------
Center 57
Flag Claims Units Chgs Paid
-------------------------------------------------
R 1 0.75 27.75 0.00
U 0 0.00 0.00 0.00
B 66 45.00 1665.00 0.00
P 0 0.00 0.00 0.00
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
1075 3267.25 172163.27 146477.63
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 1146 3332.00 174806.02 147427.63