CMS/EIP Fiscal Report Center: 52
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 379 982.75 36213.75 36.85
Subtotal (Total Children Is Unduplicated) 379 982.75 36213.75 36.85
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 6.50 487.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.50 112.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.00 225.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 8.50 471.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 43 59.00 4186.50 70.96
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 3.00 97.00 32.33
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 19 26.00 1753.50 67.44
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 47 71.50 3968.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 15.00 1125.00 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 5 5.00 242.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 6 6.00 291.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 1.00 50.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 18 18.00 873.00 48.50
Subtotal (Total Children Is Unduplicated) 102 224.00 13883.50 61.98
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 69 381.00 19050.00 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 2 18.00 900.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 48 342.25 23231.93 67.88
OCCT-97530HM-OT SESSION BY OT ASST 1 1.50 81.48 54.32
PHY-97110-PT SESSION BY LICENSED PT 51 285.00 19322.07 67.80
PHY-97110HM-PT SESSION BY PT ASST 1 1.00 54.32 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 100 396.50 26914.42 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 1 13.00 171.60 13.20
Subtotal (Total Children Is Unduplicated) 186 1438.25 89725.82 62.39
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Total 2645.00 139823.07 52.86
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Number of Children (Unduplicated) With at Least One Service 400
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Center 52
Flag Claims Units Chgs Paid
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R 3 5.00 375.00 0.00
U 0 0.00 0.00 0.00
B 2059 1351.50 58653.07 0.00
P 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 24 20.50 1043.50 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
563 1268.00 79751.50 0.00
Other 0 0.00 0.00 0.00
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Total 2649 2645.00 139823.07 0.00