CMS/EIP Fiscal Report Center: 07
Services beginning 04/01/2010 ending 06/30/2010 Date of Report:08/18/2010 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 1027 3268.25 120906.75 36.99
Subtotal (Total Children Is Unduplicated) 1027 3268.25 120906.75 36.99
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.00 150.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 6.00 450.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.00 55.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 23 43.50 3262.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 15.50 1162.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 5.50 412.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 97 186.00 10323.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 143 381.50 28537.50 74.80
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 4 4.00 194.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 50 50.00 2500.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 20 20.00 970.00 48.50
Subtotal (Total Children Is Unduplicated) 230 715.00 48017.50 67.16
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 391 2772.75 138637.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 28 241.50 16393.02 67.88
PHY-97110-PT SESSION BY LICENSED PT 18 128.75 8739.55 67.88
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 1.00 50.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 55 409.75 27813.83 67.88
Subtotal (Total Children Is Unduplicated) 455 3553.75 191633.90 53.92
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Total 7537.00 360558.15 47.84
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Number of Children (Unduplicated) With at Least One Service 1092
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Center 07
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 11 8.00 296.00 0.00
P 5181 3565.75 147022.00 147022.00
D 0 0.00 0.00 0.00
S 289 145.50 5374.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
1331 3816.75 207828.90 0.00
Other 2 1.00 37.00 0.00
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Total 6814 7537.00 360558.15 147022.00