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: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 474 1342.25 49654.00 36.99
Subtotal (Total Children Is Unduplicated) 474 1342.25 49654.00 36.99
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 6.00 450.00 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 5 7.50 416.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 66 97.50 7312.50 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 36 50.00 3750.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 81 125.50 6965.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 14 22.00 1650.00 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 17 17.00 850.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 16 16.00 776.00 48.50
Subtotal (Total Children Is Unduplicated) 154 367.50 23749.00 64.62
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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 3638.95 193746.25 53.24
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Number of Children (Unduplicated) With at Least One Service 493
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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 92 77.50 4542.67 0.00
P 2774 1849.00 81544.62 81535.37
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
712 1712.45 107658.96 0.00
Other 0 0.00 0.00 0.00
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Total 3578 3638.95 193746.25 81535.37