CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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 1533 4664.75 172272.00 36.93
Subtotal (Total Children Is Unduplicated) 1533 4664.75 172272.00 36.93
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 8.00 600.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 8.50 637.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 7.50 416.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 74 123.50 9262.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 10 19.00 1425.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 12.50 937.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 62 124.00 6882.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 50 83.00 6225.00 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 7 8.00 388.00 48.50
Subtotal (Total Children Is Unduplicated) 126 396.00 26870.75 67.86
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 8.00 353.20 44.15
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.00 30.00 30.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 327 2030.25 101512.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 12 71.25 4836.45 67.88
PHY-97110-PT SESSION BY LICENSED PT 50 289.25 19580.05 67.69
PHY-97110HM-PT SESSION BY PT ASST 9 20.00 1086.40 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 117 441.00 29732.50 67.42
SPL-92508-GROUP SPL SESSION PER CHILD 5 11.00 145.20 13.20
Subtotal (Total Children Is Unduplicated) 454 2871.75 157276.30 54.77
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Total 7932.50 356419.05 44.93
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Number of Children (Unduplicated) With at Least One Service 1574
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Center 01
Flag Claims Units Chgs Paid
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R 270 181.50 7041.50 0.00
U 0 0.00 0.00 0.00
B 3664 2688.50 101272.75 0.00
P 154 195.25 9726.75 9634.25
D 164 224.25 14950.00 0.00
S 2289 1697.50 62668.75 0.00
H 0 0.00 0.00 0.00
T 1 3.00 150.00 200.00
1035 1996.00 103966.57 3500.00
Other 609 946.50 56642.73 0.00
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Total 8186 7932.50 356419.05 13334.25