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: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 455 1033.50 38239.50 37.00
Subtotal (Total Children Is Unduplicated) 455 1033.50 38239.50 37.00
----------------------------------------------------------------------------------------------------------------
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 57 69.00 5175.00 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 58 87.50 4856.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 5.00 375.00 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) 87 199.00 12348.50 62.05
----------------------------------------------------------------------------------------------------------------
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 4485.75 222047.77 49.50
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 641
----------------------------------------------------------------------------------------------------------------
Center 57
Flag Claims Units Chgs Paid
-------------------------------------------------
R 187 184.00 6892.75 0.00
U 0 0.00 0.00 0.00
B 976 1007.00 41586.00 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
-------------------------------------------------
Total 2250 4485.75 222047.77 147501.63