CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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 1084 3905.00 144485.00 37.00
Subtotal (Total Children Is Unduplicated) 1084 3905.00 144485.00 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 4.00 300.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 2.50 187.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 3.00 225.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 15 18.00 1350.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 15 13.50 749.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 42 23.50 1762.50 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 51 36.50 2737.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 144 128.00 7104.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 48 46.00 3450.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 87 87.00 16095.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.00 275.00 275.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 23 23.00 2415.00 105.00
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 1 1.00 160.00 160.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.00 48.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 23 23.00 1115.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 5 5.00 242.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 11 11.00 533.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 22 23.00 1115.50 48.50
Subtotal (Total Children Is Unduplicated) 266 453.00 40091.25 88.50
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 481 3628.00 181400.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 65 320.50 21755.54 67.88
OCCT-97530HM-OT SESSION BY OT ASST 2 4.00 217.28 54.32
PHY-97110-PT SESSION BY LICENSED PT 48 205.25 13932.37 67.88
PHY-97110HM-PT SESSION BY PT ASST 2 5.00 271.60 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 45 238.75 16206.35 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 3 8.50 112.20 13.20
Subtotal (Total Children Is Unduplicated) 534 4410.00 233895.34 53.04
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Total 8768.00 418471.59 47.73
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Number of Children (Unduplicated) With at Least One Service 1141
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Center 04
Flag Claims Units Chgs Paid
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R 283 303.25 11974.25 0.00
U 0 0.00 0.00 0.00
B 1736 1768.00 72466.75 0.00
P 1976 2021.25 75012.25 74833.43
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 1287 4042.50 208806.74 208848.22
T 1 1.25 46.25 0.00
362 631.75 50165.35 403.64
Other 0 0.00 0.00 0.00
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Total 5645 8768.00 418471.59 284085.29