CMS/EIP Fiscal Report Center: 55
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 346 1026.25 37712.25 36.75
Subtotal (Total Children Is Unduplicated) 346 1026.25 37712.25 36.75
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Screening, Eval, and Assessment,Class #02
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.00 46.80 46.80
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.00 150.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.00 111.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 28 53.00 3975.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 20 35.50 2625.00 73.94
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 13 19.00 1425.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 30 55.50 2997.00 54.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 40 59.50 4462.50 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 5 5.00 242.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 6 8.00 388.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 8 8.00 388.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 11 11.00 533.50 48.50
Subtotal (Total Children Is Unduplicated) 106 260.50 17392.80 66.77
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 35 226.00 11300.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 61 257.75 17496.07 67.88
OCCT-97530HM-OT SESSION BY OT ASST 6 58.25 3164.14 54.32
PHY-97110-PT SESSION BY LICENSED PT 37 171.00 11593.92 67.80
PHY-97110HM-PT SESSION BY PT ASST 7 22.50 1222.20 54.32
SENS-V5264-EARMOLD 1 2.00 37.44 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 105 544.75 36977.63 67.88
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 3.00 162.96 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.00 13.20 13.20
Subtotal (Total Children Is Unduplicated) 167 1286.25 81967.56 63.73
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Total 2573.00 137072.61 53.27
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Number of Children (Unduplicated) With at Least One Service 400
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Center 55
Flag Claims Units Chgs Paid
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R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 9 9.25 399.25 0.00
P 1070 1032.75 40061.25 40098.75
D 0 0.00 0.00 0.00
S 17 18.25 713.75 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
1919 1512.75 95898.36 0.00
Other 0 0.00 0.00 0.00
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Total 3015 2573.00 137072.61 40098.75