CMS/EIP Fiscal Report Center: 52
Services beginning 04/01/2010 ending 06/30/2010 Date of Report:08/18/2010 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 412 1129.75 41791.50 36.99
Subtotal (Total Children Is Unduplicated) 412 1129.75 41791.50 36.99
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 4.50 337.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 2.00 150.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 6.00 333.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 44 69.00 5175.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 10.00 750.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 17 26.00 1950.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 50 84.00 4662.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 19.00 1425.00 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 10 10.00 485.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 4 4.00 194.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 10 10.00 500.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 16 16.00 776.00 48.50
Subtotal (Total Children Is Unduplicated) 109 260.50 16737.50 64.25
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 4.00 100.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 79 427.50 21325.00 49.88
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 3 20.00 1000.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 50 257.00 17445.16 67.88
OCCT-97530HM-OT SESSION BY OT ASST 1 9.00 488.88 54.32
PHY-97110-PT SESSION BY LICENSED PT 58 334.20 22634.10 67.73
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 2 13.00 650.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 138 828.25 56221.61 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 4 36.25 478.50 13.20
Subtotal (Total Children Is Unduplicated) 220 1929.20 120343.25 62.38
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Total 3319.45 178872.25 53.89
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Number of Children (Unduplicated) With at Least One Service 431
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Center 52
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 86 76.00 4487.17 0.00
P 2420 1552.50 68134.37 68125.12
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
693 1690.95 106250.71 0.00
Other 0 0.00 0.00 0.00
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Total 3199 3319.45 178872.25 68125.12