CMS/EIP Fiscal Report Center: 04
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 1144 4214.50 155936.50 37.00
Subtotal (Total Children Is Unduplicated) 1144 4214.50 155936.50 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 2.00 150.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 4.50 337.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 4.50 337.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 17 19.50 1462.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 28 29.00 1609.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 62 38.00 2850.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 0.50 37.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 45 32.50 2437.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 177 160.00 8880.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 56 45.00 3375.00 75.00
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 1 1.00 135.00 135.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 112 112.00 20720.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 3 3.00 825.00 275.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 42 42.00 4410.00 105.00
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 3 3.00 480.00 160.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 4 4.00 194.00 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 7 7.00 339.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 4 4.00 194.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 9 9.00 436.50 48.50
Subtotal (Total Children Is Unduplicated) 308 522.50 49308.00 94.37
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 380 2319.00 115950.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 42 212.50 14424.50 67.88
PHY-97110-PT SESSION BY LICENSED PT 26 156.75 10640.19 67.88
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 2 3.00 150.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 22 146.84 9967.50 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 1 2.00 26.40 13.20
Subtotal (Total Children Is Unduplicated) 417 2840.09 151158.59 53.22
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Total 7577.09 356403.09 47.04
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Number of Children (Unduplicated) With at Least One Service 1176
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Center 04
Flag Claims Units Chgs Paid
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R 2 2.00 87.00 0.00
U 0 0.00 0.00 0.00
B 3421 3396.00 133991.00 0.00
P 1182 1123.75 44077.77 43396.83
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 778 2488.34 127679.54 127921.86
T 0 0.00 0.00 0.00
335 567.00 50567.78 0.00
Other 0 0.00 0.00 0.00
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Total 5718 7577.09 356403.09 171318.69