CMS/EIP Fiscal Report Center: 54
Services beginning 01/01/2010 ending 03/31/2010 Date of Report:05/17/2010 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 865 3024.75 111481.00 36.86
Subtotal (Total Children Is Unduplicated) 865 3024.75 111481.00 36.86
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 4.50 337.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 15 20.50 1537.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 17 28.00 2100.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 8 12.50 693.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 6 10.50 787.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 41 58.00 4350.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 51 85.00 4717.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 62 99.50 7462.50 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 8 8.00 388.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.00 48.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 3 3.00 145.50 48.50
Subtotal (Total Children Is Unduplicated) 154 330.50 22568.25 68.29
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 159 831.75 41562.50 49.97
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 1 3.00 150.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 7 31.50 2138.22 67.88
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 5 5.00 250.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 26 151.75 10300.79 67.88
Subtotal (Total Children Is Unduplicated) 191 1023.00 54401.51 53.18
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Total 4378.25 188450.76 43.04
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Number of Children (Unduplicated) With at Least One Service 879
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Center 54
Flag Claims Units Chgs Paid
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R 3 4.50 312.50 0.00
U 0 0.00 0.00 0.00
B 5055 3861.75 160989.46 0.00
P 253 200.00 10418.04 10350.16
D 30 17.50 774.77 0.00
S 2 0.75 27.75 0.00
H 0 0.00 0.00 0.00
T 1 0.25 9.25 0.00
111 292.25 15872.74 0.00
Other 2 1.25 46.25 0.00
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Total 5457 4378.25 188450.76 10350.16