CMS/EIP Fiscal Report Center: 57
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 663 2352.75 87051.75 37.00
Subtotal (Total Children Is Unduplicated) 663 2352.75 87051.75 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 9 10.00 750.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 10 12.00 666.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 99 127.50 9562.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 102 151.00 8380.50 55.50
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 7 7.00 339.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 4 4.00 194.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 2 2.00 97.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 7 7.00 339.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 20 20.00 970.00 48.50
Subtotal (Total Children Is Unduplicated) 146 340.50 21299.00 62.55
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 397 2927.50 146375.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 33 105.50 7161.34 67.88
PHY-97110-PT SESSION BY LICENSED PT 45 163.00 11064.44 67.88
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 2 2.00 100.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 58 207.00 14051.16 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 1 0.50 6.60 13.20
Subtotal (Total Children Is Unduplicated) 448 3405.50 178758.54 52.49
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Total 6098.75 287109.29 47.08
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Number of Children (Unduplicated) With at Least One Service 801
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Center 57
Flag Claims Units Chgs Paid
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R 167 133.00 4921.00 0.00
U 0 0.00 0.00 0.00
B 1436 1506.75 59324.50 0.00
P 927 1010.00 42008.00 42008.00
D 0 0.00 0.00 0.00
S 3 5.00 285.76 217.88
H 0 0.00 0.00 0.00
T 1 3.00 150.00 150.00
1154 3441.00 180420.03 161547.92
Other 0 0.00 0.00 0.00
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Total 3688 6098.75 287109.29 203923.80