CMS/EIP Fiscal Report Center: 09
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 812 2106.00 77922.00 37.00
Subtotal (Total Children Is Unduplicated) 812 2106.00 77922.00 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 31 49.50 3712.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 5.00 375.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 14 18.00 1350.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 14 25.50 1912.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 10 17.00 943.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 180 247.50 18562.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 40 60.50 4537.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 101 128.50 9637.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 128 203.00 11266.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 22 29.00 2175.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 3 3.00 145.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 5 8.00 400.00 50.00
Subtotal (Total Children Is Unduplicated) 302 795.50 55066.50 69.22
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 217 1469.50 73475.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 128 803.75 54558.55 67.88
PHY-97110-PT SESSION BY LICENSED PT 133 718.50 48771.78 67.88
PHY-97110HM-PT SESSION BY PT ASST 5 43.00 2335.76 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 148 871.50 59157.42 67.88
Subtotal (Total Children Is Unduplicated) 460 3906.25 238298.51 61.00
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Total 6807.75 371287.01 54.54
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Number of Children (Unduplicated) With at Least One Service 1005
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Center 09
Flag Claims Units Chgs Paid
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R 15 16.00 629.00 27.75
U 0 0.00 0.00 0.00
B 1024 983.50 50177.64 335.00
P 2782 2450.50 114535.40 114475.64
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 1 0.50 18.50 18.50
T 0 0.00 0.00 0.00
1227 3357.25 205926.47 0.00
Other 0 0.00 0.00 0.00
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Total 5049 6807.75 371287.01 114856.89