CMS/EIP Fiscal Report Center: 09
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 750 1878.75 69513.75 37.00
Subtotal (Total Children Is Unduplicated) 750 1878.75 69513.75 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 28 39.00 2925.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.00 150.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 15 18.50 1387.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 15 26.00 1950.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 12 19.00 1054.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 113 127.50 9562.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 13 23.50 1762.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 85 103.00 7725.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 158 241.50 13403.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 15 16.00 1200.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 7 7.00 339.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 2 2.00 97.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 4.00 194.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 2.00 100.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 3 3.00 145.50 48.50
Subtotal (Total Children Is Unduplicated) 274 635.00 42044.75 66.21
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 152 1123.25 56162.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 111 625.00 42425.00 67.88
OCCT-97530HM-OT SESSION BY OT ASST 1 0.50 27.16 54.32
PHY-97110-PT SESSION BY LICENSED PT 132 790.00 53625.20 67.88
PHY-97110HM-PT SESSION BY PT ASST 7 56.25 3055.50 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 115 626.75 42543.79 67.88
Subtotal (Total Children Is Unduplicated) 368 3221.75 197839.15 61.41
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Total 5735.50 309397.65 53.94
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Number of Children (Unduplicated) With at Least One Service 889
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Center 09
Flag Claims Units Chgs Paid
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R 35 22.75 841.75 0.00
U 0 0.00 0.00 0.00
B 653 546.25 27351.03 429.50
P 2755 2407.00 110638.14 193524.89
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
1040 2757.50 170492.73 0.00
Other 6 2.00 74.00 0.00
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Total 4489 5735.50 309397.65 193954.39