CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2010 ending 09/30/2010 Date of Report:11/17/2010 Page: 1
Payclass Filters:TPIN
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
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 30.000000 1110.0000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 2 3.000000 111.0000 37.0000
Subtotal (Total Children Is Unduplicated) 3 33.000000 1221.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 1 1.198190 66.4995 55.4995
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 8 14.529066 1813.6400 124.8281
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 5.861160 560.2470 95.5857
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 13 23.072602 2557.8094 110.8592
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 15.392267 1999.0400 129.8727
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 2.210510 107.2097 48.5002
PSTH-97001-EVAL BY LICENSED PT, INITIAL 6 6.000000 291.0000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 9 10.000000 1217.5800 121.7580
Subtotal (Total Children Is Unduplicated) 32 84.263795 9024.0256 107.0926
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 49.6200 49.6200
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 8.000000 400.0000 50.0000
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 1 7.000000 350.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 12 66.500000 4514.0200 67.8800
PHY-97110-PT SESSION BY LICENSED PT 24 186.250000 12642.6500 67.8800
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 20 96.250000 6533.4500 67.8800
SPL-92508-GROUP SPL SESSION PER CHILD 2 4.750000 62.7000 13.2000
Subtotal (Total Children Is Unduplicated) 45 370.750000 24602.4400 66.3586
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Total 488.013795 34847.4656 71.4067
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Number of Children (Unduplicated) With at Least One Service 72
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Center 53
Flag Claims Units Chgs Paid
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R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 10 12.053285 781.7159 781.7200
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
523 475.960510 34065.7497 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 533 488.013795 34847.4656 781.7200