CMS/EIP Fiscal Report Center: 57
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 541 1894.25 69976.25 36.94
Subtotal (Total Children Is Unduplicated) 541 1894.25 69976.25 36.94
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 14 17.00 1275.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 2.50 187.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 17 22.50 1248.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 125 142.50 10687.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 149 186.50 10350.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 19 23.50 1762.50 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 15 16.00 776.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 11 11.00 533.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 9 9.00 436.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 19 19.00 921.50 48.50
Subtotal (Total Children Is Unduplicated) 202 449.50 28179.50 62.69
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 304 2573.00 128650.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 35 153.50 10419.58 67.88
PHY-97110-PT SESSION BY LICENSED PT 41 202.00 13711.76 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 44 155.75 10572.31 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 2 3.00 39.60 13.20
Subtotal (Total Children Is Unduplicated) 351 3087.25 163393.25 52.93
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Total 5431.00 261549.00 48.16
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Number of Children (Unduplicated) With at Least One Service 645
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Center 57
Flag Claims Units Chgs Paid
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R 259 269.00 10553.50 0.00
U 0 0.00 0.00 0.00
B 385 397.00 17102.50 0.00
P 1353 1464.25 57542.75 57542.75
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 9 23.50 1182.44 1182.44
1181 3277.25 175167.81 132562.99
Other 0 0.00 0.00 0.00
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Total 3187 5431.00 261549.00 191288.18