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: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 1181 4651.75 172114.75 37.00
Subtotal (Total Children Is Unduplicated) 1181 4651.75 172114.75 37.00
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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 15 14.00 1050.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 40 39.50 2192.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 66 36.00 2700.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 3.00 225.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 54 39.00 2925.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 172 146.50 8130.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 61 55.00 4125.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 99 99.00 18315.00 185.00
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 13 13.00 630.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 38 38.00 1843.00 48.50
Subtotal (Total Children Is Unduplicated) 330 550.00 48046.50 87.36
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 451 3778.00 188900.00 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 35 161.75 10979.59 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) 496 4295.25 223635.83 52.07
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Total 9497.00 443797.08 46.73
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Number of Children (Unduplicated) With at Least One Service 1233
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Center 04
Flag Claims Units Chgs Paid
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R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 1866 1886.75 79528.25 0.00
P 3102 3101.50 117929.50 115163.52
D 4 7.75 338.75 338.75
S 0 0.00 0.00 0.00
H 1212 4005.50 204047.88 204607.83
T 0 0.00 0.00 0.00
298 495.50 41952.70 0.00
Other 0 0.00 0.00 0.00
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Total 6482 9497.00 443797.08 320110.10