CMS/EIP Fiscal Report Center: 05
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 337 1154.25 42707.25 37.00
Subtotal (Total Children Is Unduplicated) 337 1154.25 42707.25 37.00
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Screening, Eval, and Assessment,Class #02
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 1 1.00 125.00 125.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.00 75.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 15 19.00 1425.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 6.00 450.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 19 23.00 1725.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 7 9.50 527.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 6.50 487.50 75.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 5 5.00 363.90 72.78
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 1 1.00 50.15 50.15
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 2 2.00 97.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 9 9.00 436.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 5 5.00 242.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 3 3.00 150.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 9 9.00 436.50 48.50
Subtotal (Total Children Is Unduplicated) 59 101.00 6666.30 66.00
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 104 309.25 15462.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 38 99.25 6737.09 67.88
OCCT-97530HM-OT SESSION BY OT ASST 2 2.50 135.80 54.32
PHY-97110-PT SESSION BY LICENSED PT 76 289.00 19617.32 67.88
PHY-97110HM-PT SESSION BY PT ASST 1 0.50 27.16 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 79 258.00 17513.04 67.88
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 3 6.00 325.92 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 7 21.00 277.20 13.20
Subtotal (Total Children Is Unduplicated) 175 985.50 60096.03 60.98
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Total 2240.75 109469.58 48.85
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Number of Children (Unduplicated) With at Least One Service 345
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Center 05
Flag Claims Units Chgs Paid
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R 42 28.25 1045.25 0.00
U 0 0.00 0.00 0.00
B 1940 1052.50 39275.62 0.00
P 1 1.00 75.00 75.00
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 0 0.00 0.00 0.00
1509 1159.00 69073.71 0.00
Other 0 0.00 0.00 0.00
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Total 3492 2240.75 109469.58 75.00