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:TPIN
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 3 23.25 860.25 37.00
Subtotal (Total Children Is Unduplicated) 3 23.25 860.25 37.00
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
EXIT-EXIT-TRANSITION ASSESSMENT 10 21.25 1062.50 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 6.00 450.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.00 75.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 9.50 712.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 4.00 222.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 8.50 637.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 20 30.50 2287.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 15 26.50 1470.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 27 41.50 3112.50 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 6 6.00 291.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 0.81 39.66 48.96
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 4 4.00 194.00 48.50
Subtotal (Total Children Is Unduplicated) 82 160.56 10603.41 66.04
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 5 6.00 300.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 14 12.50 625.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 2 1.00 25.00 25.00
CONOP-CONOP-CONSULT, OT, PHONE 1 1.00 25.00 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.25 62.50 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 55 280.75 14037.50 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 7 15.00 750.00 50.00
INTR-INTR-INTERPRETER 1 2.00 100.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 21 59.20 4032.64 68.12
OCCT-97530HM-OT SESSION BY OT ASST 1 0.20 11.00 55.00
PHY-97110-PT SESSION BY LICENSED PT 10 22.47 1534.39 68.29
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 1.00 50.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 27 172.70 11745.33 68.01
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 0.75 40.74 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 1 0.50 6.60 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 3 186.00 130.20 0.70
Subtotal (Total Children Is Unduplicated) 122 762.32 33475.90 43.91
----------------------------------------------------------------------------------------------------------------
Total 946.13 44939.56 47.50
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 190
----------------------------------------------------------------------------------------------------------------
Center 54
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 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 0 0.00 0.00 0.00
668 946.13 44939.56 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 668 946.13 44939.56 0.00