CMS/EIP Fiscal Report Center: 51
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 517 2238.25 82815.25 37.00
Subtotal (Total Children Is Unduplicated) 517 2238.25 82815.25 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.00 75.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 62 71.00 5250.00 73.94
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 9 11.50 862.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 11.00 825.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 7 9.00 499.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 77 89.00 6637.50 74.58
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 1 1.00 40.50 40.50
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 13 20.00 970.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 7 7.00 339.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 8 8.00 388.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 12 12.00 582.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 12 12.00 582.00 48.50
Subtotal (Total Children Is Unduplicated) 128 253.50 17126.50 67.56
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 5.00 3415.00 683.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 172 1091.75 54587.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 68 413.25 28051.41 67.88
OCCT-97530HM-OT SESSION BY OT ASST 10 22.50 1222.20 54.32
PHY-97110-PT SESSION BY LICENSED PT 88 490.75 33155.47 67.56
PHY-97110HM-PT SESSION BY PT ASST 20 124.25 6749.26 54.32
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 2 2.00 100.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 104 572.50 38677.46 67.56
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 2.25 122.22 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 3 5.75 75.90 13.20
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 1 86.00 4300.00 50.00
Subtotal (Total Children Is Unduplicated) 259 2816.00 170456.42 60.53
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Total 5307.75 270398.17 50.94
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Number of Children (Unduplicated) With at Least One Service 537
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Center 51
Flag Claims Units Chgs Paid
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R 4 1.75 64.75 0.00
U 0 0.00 0.00 0.00
B 3208 2290.00 86458.10 0.00
P 0 0.00 0.00 0.00
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
1200 3014.50 183762.82 0.00
Other 1 1.50 112.50 0.00
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Total 4413 5307.75 270398.17 0.00