CMS/EIP Fiscal Report Center: 55
Services beginning 01/01/2010 ending 03/31/2010 Date of Report:05/17/2010 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 1 2.00 74.00 37.00
Subtotal (Total Children Is Unduplicated) 1 2.00 74.00 37.00
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Screening, Eval, and Assessment,Class #02
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-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
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) 94 191.50 12440.25 64.96
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 53 334.00 16700.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 52 322.00 21857.36 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 157 921.00 62517.48 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 1793.25 114816.27 64.03
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Total 1986.75 127330.52 64.09
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Number of Children (Unduplicated) With at Least One Service 278
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Center 55
Flag Claims Units Chgs Paid
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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
2530 1986.75 127330.52 0.00
Other 0 0.00 0.00 0.00
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Total 2530 1986.75 127330.52 0.00