CMS/EIP Fiscal Report Center: 05
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 417 1386.00 51282.00 37.00
Subtotal (Total Children Is Unduplicated) 417 1386.00 51282.00 37.00
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 10 17.50 1312.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 3.00 225.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 12.00 900.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 22 44.00 2442.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 2.50 187.50 75.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 6 6.00 436.68 72.78
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 6 6.00 300.90 50.15
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.00 48.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 3.00 145.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 3 3.00 145.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 15 16.00 800.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 3 3.00 145.50 48.50
Subtotal (Total Children Is Unduplicated) 55 117.00 7089.58 60.59
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 93 527.25 26362.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 38 98.00 6652.24 67.88
PHY-97110-PT SESSION BY LICENSED PT 60 205.25 13932.37 67.88
PHY-97110HM-PT SESSION BY PT ASST 2 1.50 81.48 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 74 212.00 14390.56 67.88
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 2 3.00 162.96 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 2 3.00 39.60 13.20
Subtotal (Total Children Is Unduplicated) 160 1050.00 61621.71 58.69
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Total 2553.00 119993.29 47.00
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Number of Children (Unduplicated) With at Least One Service 429
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Center 05
Flag Claims Units Chgs Paid
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R 1 1.00 72.78 0.00
U 0 0.00 0.00 0.00
B 2378 1291.50 48183.70 0.00
P 3 2.00 74.00 27.75
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 1 2.25 83.25 0.00
1514 1256.25 71579.56 0.00
Other 0 0.00 0.00 0.00
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Total 3897 2553.00 119993.29 27.75