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: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 1151 4285.75 158572.75 37.00
Subtotal (Total Children Is Unduplicated) 1151 4285.75 158572.75 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 9 6.00 450.00 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 6 4.00 300.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 6.00 450.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 27 25.00 1387.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 58 34.00 2550.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 4.50 337.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 73 53.50 4012.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 181 162.00 8991.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 50 44.50 3337.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 89 89.00 16465.00 185.00
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) 299 496.00 43490.50 87.68
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 461 3915.00 195750.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 47 296.00 20092.48 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) 500 4535.00 237432.84 52.36
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Total 9316.75 439496.09 47.17
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Number of Children (Unduplicated) With at Least One Service 1220
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Center 04
Flag Claims Units Chgs Paid
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R 30 27.00 999.00 0.00
U 0 0.00 0.00 0.00
B 2043 2058.75 85576.25 0.00
P 2550 2572.25 100331.09 95784.71
D 4 11.00 573.30 569.70
S 0 0.00 0.00 0.00
H 1276 4249.00 218444.80 218786.14
T 0 0.00 0.00 0.00
230 398.75 33571.65 450.00
Other 0 0.00 0.00 0.00
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Total 6133 9316.75 439496.09 315590.55