CMS/EIP Fiscal Report Center: 57
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 620 2361.00 87357.00 37.00
Subtotal (Total Children Is Unduplicated) 620 2361.00 87357.00 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 4.00 300.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 7.50 416.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 110 143.50 10762.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 117 179.50 9962.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 8.00 600.00 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 5 5.00 242.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 9 9.00 436.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 15 15.00 727.50 48.50
Subtotal (Total Children Is Unduplicated) 145 373.50 23571.00 63.11
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 355 3119.00 155900.00 49.98
OCCT-97530-OT SESSION BY LICENSED OT 33 85.50 5803.74 67.88
PHY-97110-PT SESSION BY LICENSED PT 38 114.50 7772.26 67.88
PHY-97110HM-PT SESSION BY PT ASST 1 2.50 135.80 54.32
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 2 2.00 100.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 55 139.75 9316.53 66.67
Subtotal (Total Children Is Unduplicated) 409 3463.25 179028.33 51.69
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Total 6197.75 289956.33 46.78
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Number of Children (Unduplicated) With at Least One Service 701
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Center 57
Flag Claims Units Chgs Paid
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R 118 149.50 5701.00 0.00
U 0 0.00 0.00 0.00
B 466 538.00 22361.25 0.00
P 1850 1972.25 78609.00 78609.00
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 11 34.00 1735.76 1735.76
1130 3504.00 181549.32 164327.91
Other 0 0.00 0.00 0.00
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Total 3575 6197.75 289956.33 244672.67