CMS/EIP Fiscal Report Center: 07
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 766 2477.75 91521.75 36.94
Subtotal (Total Children Is Unduplicated) 766 2477.75 91521.75 36.94
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 7.50 562.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 4.50 249.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 6 11.50 862.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.00 150.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 2.50 187.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 52 103.50 5716.50 55.23
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 108 300.50 22425.00 74.63
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 1 1.00 72.78 72.78
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 2.00 97.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.00 97.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 17 17.00 850.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 6 6.00 291.00 48.50
Subtotal (Total Children Is Unduplicated) 148 460.00 31561.53 68.61
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 236 1537.25 76862.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 18 52.50 3563.70 67.88
PHY-97110-PT SESSION BY LICENSED PT 15 112.00 7602.56 67.88
PHY-97110HM-PT SESSION BY PT ASST 1 5.00 271.60 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 29 88.00 5973.44 67.88
Subtotal (Total Children Is Unduplicated) 279 1794.75 94273.80 52.53
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Total 4732.50 217357.08 45.93
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Number of Children (Unduplicated) With at Least One Service 798
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Center 07
Flag Claims Units Chgs Paid
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R 18 22.75 1278.75 0.00
U 0 0.00 0.00 0.00
B 3552 2440.25 98103.78 0.00
P 229 246.75 13279.75 13279.75
D 0 0.00 0.00 0.00
S 195 109.25 4042.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
726 1913.50 100652.55 0.00
Other 0 0.00 0.00 0.00
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Total 4720 4732.50 217357.08 13279.75