CMS/EIP Fiscal Report Center: 53
Services beginning 04/01/2010 ending 06/30/2010 Date of Report:08/18/2010 Page: 1
Payclass Filters:MED
Bill Flag Filter:RBPU
Eligibility Filter:All
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 478 1510.75 55749.75 36.90
Subtotal (Total Children Is Unduplicated) 478 1510.75 55749.75 36.90
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 9.00 675.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 3.00 225.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 6 10.00 750.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 10 16.00 888.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 23 45.50 3412.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 19 40.00 3000.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 99 195.00 10822.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 69 151.50 11362.50 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 2.00 97.00 48.50
Subtotal (Total Children Is Unduplicated) 144 472.00 31232.50 66.17
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EI Services,Class #03
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 1 1.00 73.42 73.42
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 13 15.00 375.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 88 310.50 15525.00 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 5 11.00 550.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 7 20.00 1316.92 65.85
OCCT-97530HM-OT SESSION BY OT ASST 8 20.00 1086.40 54.32
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 11 95.00 4750.00 50.00
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 1 3.00 150.00 50.00
Subtotal (Total Children Is Unduplicated) 118 475.50 23826.74 50.11
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Total 2458.25 110808.99 45.08
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Number of Children (Unduplicated) With at Least One Service 529
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Center 53
Flag Claims Units Chgs Paid
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R 7 6.50 240.50 0.00
U 0 0.00 0.00 0.00
B 1712 1504.00 61416.96 0.00
P 787 947.75 49151.53 48151.53
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
0 0.00 0.00 0.00
Other 0 0.00 0.00 0.00
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Total 2506 2458.25 110808.99 48151.53