CMS/EIP Fiscal Report Center: 55
Services beginning 01/01/2010 ending 03/31/2010 Date of Report:05/17/2010 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 351 1035.00 38128.50 36.84
Subtotal (Total Children Is Unduplicated) 351 1035.00 38128.50 36.84
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 1 1.00 125.00 125.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 5.00 375.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.50 262.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 2.50 187.50 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 39 55.00 4125.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 17 30.00 2250.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 13 14.50 1087.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 23 37.50 2081.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 59 61.50 4612.50 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 3 3.00 145.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 7 7.00 339.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 2 2.00 97.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 10 11.00 533.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 19 19.00 921.50 48.50
Subtotal (Total Children Is Unduplicated) 119 256.50 17365.25 67.70
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 53 337.00 16850.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 52 324.50 22027.06 67.88
OCCT-97530HM-OT SESSION BY OT ASST 10 24.00 1303.68 54.32
PHY-97110-PT SESSION BY LICENSED PT 33 160.75 10911.71 67.88
PHY-97110HM-PT SESSION BY PT ASST 9 24.00 1303.68 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 157 923.00 62653.24 67.88
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 2 3.00 162.96 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 3 4.50 59.40 13.20
Subtotal (Total Children Is Unduplicated) 233 1800.75 115271.73 64.01
----------------------------------------------------------------------------------------------------------------
Total 3092.25 170765.48 55.22
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 419
----------------------------------------------------------------------------------------------------------------
Center 55
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 2 1.00 37.00 0.00
P 1198 1094.25 42752.75 42715.25
D 0 0.00 0.00 0.00
S 1 0.50 18.50 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
2545 1996.50 127957.23 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 3746 3092.25 170765.48 42715.25