CMS/EIP Fiscal Report Center: 09
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 748 2163.00 79905.25 36.94
Subtotal (Total Children Is Unduplicated) 748 2163.00 79905.25 36.94
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 28 42.50 3187.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 6.00 450.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 15 19.00 1425.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 10 18.50 1387.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 7 11.00 610.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 101 113.00 8475.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 14 22.00 1650.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 77 87.50 6562.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 93 141.50 7853.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 14 15.00 1125.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 2 2.00 97.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 2 2.00 97.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.00 97.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 3 3.00 150.00 50.00
Subtotal (Total Children Is Unduplicated) 219 486.00 33215.75 68.35
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 179 1294.25 64652.50 49.95
OCCT-97530-OT SESSION BY LICENSED OT 129 767.25 52080.93 67.88
PHY-97110-PT SESSION BY LICENSED PT 136 774.25 52450.83 67.74
PHY-97110HM-PT SESSION BY PT ASST 6 49.00 2661.68 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 142 822.75 55848.27 67.88
Subtotal (Total Children Is Unduplicated) 422 3707.50 227694.21 61.41
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Total 6356.50 340815.21 53.62
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Number of Children (Unduplicated) With at Least One Service 874
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Center 09
Flag Claims Units Chgs Paid
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R 6 7.75 286.75 0.00
U 0 0.00 0.00 0.00
B 825 745.00 35047.57 204.26
P 2887 2453.00 110333.52 110204.77
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 0 0.00 0.00 0.00
1175 3150.75 195147.37 151.51
Other 0 0.00 0.00 0.00
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Total 4893 6356.50 340815.21 110560.54