CMS/EIP Fiscal Report Center: 55
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 349 1032.75 38073.00 36.87
Subtotal (Total Children Is Unduplicated) 349 1032.75 38073.00 36.87
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 28 50.50 3787.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 21 37.00 2775.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 17 27.50 2062.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 38 68.50 3774.00 55.09
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 48 72.00 5400.00 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 10 10.00 485.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 8 8.00 388.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 16 16.00 776.00 48.50
Subtotal (Total Children Is Unduplicated) 122 292.50 19593.50 66.99
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 44 278.25 13912.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 67 346.00 23466.14 67.82
OCCT-97530HM-OT SESSION BY OT ASST 9 44.50 2417.24 54.32
PHY-97110-PT SESSION BY LICENSED PT 40 157.00 10650.38 67.84
PHY-97110HM-PT SESSION BY PT ASST 10 40.50 2199.96 54.32
SENS-V5264-EARMOLD 1 2.00 37.44 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 135 786.09 53325.65 67.84
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.00 13.20 13.20
Subtotal (Total Children Is Unduplicated) 204 1655.34 106022.51 64.05
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Total 2980.59 163689.01 54.92
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Number of Children (Unduplicated) With at Least One Service 426
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Center 55
Flag Claims Units Chgs Paid
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R 5 4.75 175.75 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 1075 1070.25 42139.50 42139.50
D 1 1.00 37.00 0.00
S 2 2.25 83.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
2508 1902.34 121253.51 0.00
Other 0 0.00 0.00 0.00
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Total 3591 2980.59 163689.01 42139.50