CMS/EIP Fiscal Report Center: 04
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 Page: 1
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
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 1027 3832.50 141802.50 37.00
Subtotal (Total Children Is Unduplicated) 1027 3832.50 141802.50 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 5.00 375.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 0.50 37.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 3.00 225.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 4.00 300.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 25 23.00 1276.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 39 23.00 1725.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 1.50 112.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 59 45.50 3412.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 140 128.00 7104.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 40 34.50 2587.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 77 77.00 14245.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 3 3.00 825.00 275.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 22 22.00 2310.00 105.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 7 7.00 339.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 6 6.00 291.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 7 7.00 339.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 4 4.00 194.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 18 18.00 873.00 48.50
Subtotal (Total Children Is Unduplicated) 246 412.00 36572.50 88.77
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 457 3892.00 194600.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 46 295.00 20024.60 67.88
OCCT-97530HM-OT SESSION BY OT ASST 2 4.50 244.44 54.32
PHY-97110-PT SESSION BY LICENSED PT 25 158.75 10775.95 67.88
PHY-97110HM-PT SESSION BY PT ASST 4 14.50 787.64 54.32
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 2.00 100.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 28 142.25 9655.93 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 1 2.00 26.40 13.20
Subtotal (Total Children Is Unduplicated) 496 4511.00 236214.96 52.36
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Total 8755.50 414589.96 47.35
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Number of Children (Unduplicated) With at Least One Service 1096
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Center 04
Flag Claims Units Chgs Paid
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R 25 21.50 795.50 0.00
U 0 0.00 0.00 0.00
B 1805 1815.50 74542.00 0.00
P 2314 2292.00 89073.84 85333.68
D 4 11.00 573.30 569.70
S 0 0.00 0.00 0.00
H 1268 4225.00 217226.92 217568.26
T 0 0.00 0.00 0.00
219 390.50 32378.40 450.00
Other 0 0.00 0.00 0.00
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Total 5635 8755.50 414589.96 303921.64