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: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 1267 3520.00 130240.00 37.00
Subtotal (Total Children Is Unduplicated) 1267 3520.00 130240.00 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 5.00 375.00 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 6 8.00 433.00 54.13
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 58 78.00 5850.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 30 57.50 4275.00 74.35
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 100 133.50 7409.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 69 81.50 6112.50 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) 190 379.50 25442.75 67.04
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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 89 338.00 16900.00 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 20 66.75 4530.99 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) 180 830.50 50224.45 60.48
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Total 4730.00 205907.20 43.53
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Number of Children (Unduplicated) With at Least One Service 1302
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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 3248 2380.75 88838.25 0.00
P 350 243.25 9000.25 9000.20
D 4 1.25 46.25 0.00
S 1028 804.00 29748.00 0.00
H 0 0.00 0.00 0.00
T 1 1.25 46.25 0.00
484 960.75 57916.32 0.00
Other 291 333.75 20126.88 0.00
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Total 5414 4730.00 205907.20 9000.20