CMS/EIP Fiscal Report Center: 04
Services beginning 07/01/2009 ending 09/30/2009 Date of Report:11/17/2009 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 1034 4081.00 150997.00 37.00
Subtotal (Total Children Is Unduplicated) 1034 4081.00 150997.00 37.00
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 12 8.50 637.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 2.00 150.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 2.50 187.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 13 13.00 975.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 37 36.50 2025.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 42 22.50 1687.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 2.00 150.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 37 28.00 2100.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 126 105.50 5855.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 44 39.50 2962.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 82 82.00 15170.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 2 2.00 550.00 275.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 31 31.00 3255.00 105.00
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 1 1.00 160.00 160.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 6 6.00 291.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 12 12.00 582.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 2 2.00 97.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 12 12.00 582.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 38 38.00 1843.00 48.50
Subtotal (Total Children Is Unduplicated) 264 446.00 39261.00 88.03
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 449 3757.00 187850.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 40 183.50 12455.98 67.88
OCCT-97530HM-OT SESSION BY OT ASST 2 6.50 353.08 54.32
PHY-97110-PT SESSION BY LICENSED PT 34 160.75 10911.71 67.88
PHY-97110HM-PT SESSION BY PT ASST 1 1.00 54.32 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 38 159.50 10826.86 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 3 5.00 66.00 13.20
Subtotal (Total Children Is Unduplicated) 494 4273.25 222517.95 52.07
----------------------------------------------------------------------------------------------------------------
Total 8800.25 412775.95 46.91
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1086
----------------------------------------------------------------------------------------------------------------
Center 04
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 1583 1585.00 65953.50 0.00
P 2795 2743.50 104091.50 101816.73
D 4 7.75 338.75 338.75
S 0 0.00 0.00 0.00
H 1205 3982.50 202881.50 203441.45
T 0 0.00 0.00 0.00
284 481.50 39510.70 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 5871 8800.25 412775.95 305596.93