CMS/EIP Fiscal Report Center: 07
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 971 2844.25 105126.25 36.96
Subtotal (Total Children Is Unduplicated) 971 2844.25 105126.25 36.96
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.00 150.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 12.00 900.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 4.00 211.00 52.75
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 13 24.50 1837.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 7.50 562.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 13 13.00 975.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 80 155.00 8602.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 131 365.00 27337.50 74.90
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 1 1.00 72.78 72.78
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.00 48.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 4 4.00 194.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 30 30.00 1500.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 13 13.00 630.50 48.50
Subtotal (Total Children Is Unduplicated) 205 632.00 43021.78 68.07
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 299 1985.50 99275.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 27 210.00 14254.80 67.88
OCCT-97530HM-OT SESSION BY OT ASST 1 1.00 54.32 54.32
PHY-97110-PT SESSION BY LICENSED PT 28 236.25 16036.65 67.88
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 1.00 50.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 47 209.00 14186.92 67.88
Subtotal (Total Children Is Unduplicated) 362 2642.75 143857.69 54.43
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Total 6119.00 292005.72 47.72
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Number of Children (Unduplicated) With at Least One Service 1003
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Center 07
Flag Claims Units Chgs Paid
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R 21 10.50 521.50 0.00
U 0 0.00 0.00 0.00
B 1178 729.50 27774.50 0.00
P 3496 2480.75 105037.78 105037.78
D 0 0.00 0.00 0.00
S 64 35.00 1295.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
1045 2863.25 157376.94 0.00
Other 0 0.00 0.00 0.00
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Total 5804 6119.00 292005.72 105037.78