CMS/EIP Fiscal Report Center: 57
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 757 2830.50 104728.50 37.00
Subtotal (Total Children Is Unduplicated) 757 2830.50 104728.50 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 7.00 525.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 8 12.50 693.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 115 134.50 10087.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 162 245.50 13625.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.00 225.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 5 6.00 291.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 2.00 97.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 6 6.00 291.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 3 3.00 145.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 18 18.00 873.00 48.50
Subtotal (Total Children Is Unduplicated) 196 437.50 26854.00 61.38
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 427 3686.00 184300.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 33 107.00 7263.16 67.88
PHY-97110-PT SESSION BY LICENSED PT 54 180.00 12218.40 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 72 274.00 18599.12 67.88
Subtotal (Total Children Is Unduplicated) 495 4247.00 222380.68 52.36
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Total 7515.00 353963.18 47.10
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Number of Children (Unduplicated) With at Least One Service 869
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Center 57
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 2807 2969.00 115470.65 0.00
P 183 262.25 14504.00 14504.00
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 1 2.00 100.00 100.00
1411 4281.75 223888.53 204364.52
Other 0 0.00 0.00 0.00
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Total 4402 7515.00 353963.18 218968.52