CMS/EIP Fiscal Report Center: 10
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 1171 4471.00 165427.00 37.00
Subtotal (Total Children Is Unduplicated) 1171 4471.00 165427.00 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 8 13.00 975.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 14 27.50 2062.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 6 8.00 600.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 4.50 337.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 17 33.00 1831.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 114 193.50 14512.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 79 132.50 9937.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 80 128.50 9637.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 118 216.00 11988.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 88 114.00 8550.00 75.00
Subtotal (Total Children Is Unduplicated) 212 870.50 60432.00 69.42
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 7 43.00 1075.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 105 780.25 39012.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 54 193.75 13050.05 67.36
OCCT-97530HM-OT SESSION BY OT ASST 9 19.00 1032.08 54.32
PHY-97110-PT SESSION BY LICENSED PT 99 404.75 27474.43 67.88
PHY-97110HM-PT SESSION BY PT ASST 2 2.00 108.64 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 96 297.00 20132.36 67.79
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 2.00 108.64 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 2 8.50 112.20 13.20
Subtotal (Total Children Is Unduplicated) 253 1750.25 102105.90 58.34
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Total 7091.75 327964.90 46.25
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Number of Children (Unduplicated) With at Least One Service 1184
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Center 10
Flag Claims Units Chgs Paid
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R 66 48.50 1794.50 0.00
U 0 0.00 0.00 0.00
B 4520 3110.00 120419.00 83.25
P 2617 2010.50 96421.25 96421.25
D 4 3.00 111.00 111.00
S 289 169.50 7113.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
743 1750.25 102105.90 0.00
Other 0 0.00 0.00 0.00
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Total 8239 7091.75 327964.90 96615.50