CMS/EIP Fiscal Report Center: 01
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 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 1075 2981.50 110315.50 37.00
Subtotal (Total Children Is Unduplicated) 1075 2981.50 110315.50 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.00 225.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 4.00 300.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 4.00 300.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 7.00 377.50 53.93
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 47 63.50 4762.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 23 45.00 3375.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 74 104.00 5772.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 38 45.50 3412.50 75.00
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 2 2.00 97.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 6 6.00 291.00 48.50
Subtotal (Total Children Is Unduplicated) 140 284.00 18912.50 66.59
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 2.00 523.80 261.90
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 84 319.00 15950.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 3 2.50 167.76 67.10
OCCT-97530HM-OT SESSION BY OT ASST 3 7.00 380.24 54.32
PHY-97110-PT SESSION BY LICENSED PT 19 65.75 4463.11 67.88
PHY-97110HM-PT SESSION BY PT ASST 2 7.00 380.24 54.32
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 2 5.00 250.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 80 402.25 27091.42 67.35
Subtotal (Total Children Is Unduplicated) 174 810.50 49206.57 60.71
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Total 4076.00 178434.57 43.78
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Number of Children (Unduplicated) With at Least One Service 1107
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Center 01
Flag Claims Units Chgs Paid
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R 8 5.00 185.00 0.00
U 0 0.00 0.00 0.00
B 2797 1990.75 74239.25 0.00
P 309 201.75 7464.75 7464.70
D 4 1.25 46.25 0.00
S 911 702.50 25992.50 0.00
H 0 0.00 0.00 0.00
T 1 1.25 46.25 0.00
459 929.50 56026.19 0.00
Other 208 244.00 14434.38 0.00
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Total 4697 4076.00 178434.57 7464.70