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: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 807 2609.25 96378.00 36.94
Subtotal (Total Children Is Unduplicated) 807 2609.25 96378.00 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 4 4.50 337.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 61 121.50 6715.50 55.27
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 125 349.00 26062.50 74.68
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 2 2.00 145.56 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 20 20.00 1000.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 6 6.00 291.00 48.50
Subtotal (Total Children Is Unduplicated) 174 532.50 36570.81 68.68
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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 4936.50 227222.61 46.03
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Number of Children (Unduplicated) With at Least One Service 840
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Center 07
Flag Claims Units Chgs Paid
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R 21 26.75 1502.75 0.00
U 0 0.00 0.00 0.00
B 3707 2585.25 104394.31 0.00
P 265 293.00 16157.00 16157.00
D 0 0.00 0.00 0.00
S 201 112.00 4144.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
730 1919.50 101024.55 0.00
Other 0 0.00 0.00 0.00
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Total 4924 4936.50 227222.61 16157.00