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: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 867 2403.75 88813.00 36.95
Subtotal (Total Children Is Unduplicated) 867 2403.75 88813.00 36.95
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 33 47.50 3562.50 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 19 23.00 1725.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 11 19.50 1462.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 11 17.00 943.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 157 177.50 13312.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 28 49.00 3675.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 122 138.00 10350.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 149 220.00 12210.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 25 26.00 1950.00 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 5 5.00 250.00 50.00
Subtotal (Total Children Is Unduplicated) 332 735.50 50230.50 68.29
----------------------------------------------------------------------------------------------------------------
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
----------------------------------------------------------------------------------------------------------------
Total 6846.75 366737.71 53.56
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1010
----------------------------------------------------------------------------------------------------------------
Center 09
Flag Claims Units Chgs Paid
-------------------------------------------------
R 6 7.75 286.75 0.00
U 0 0.00 0.00 0.00
B 899 833.25 39597.82 204.26
P 3205 2836.50 130318.27 130089.52
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
1187 3169.25 196534.87 151.51
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 5297 6846.75 366737.71 130445.29