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: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 1218 4416.50 163410.50 37.00
Subtotal (Total Children Is Unduplicated) 1218 4416.50 163410.50 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 5 3.50 262.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 16 18.50 1387.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 16 14.50 804.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 64 35.50 2626.00 73.97
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 4.00 300.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 67 45.50 3412.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 190 165.00 9103.00 55.17
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 62 61.50 4612.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 106 106.00 19610.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 3 3.00 825.00 275.00
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) 328 550.50 49061.75 89.12
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 484 3653.00 182650.00 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 49 213.25 14475.41 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) 537 4443.00 235688.38 53.05
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Total 9410.00 448160.63 47.63
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Number of Children (Unduplicated) With at Least One Service 1275
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Center 04
Flag Claims Units Chgs Paid
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R 322 337.50 13468.00 0.00
U 0 0.00 0.00 0.00
B 2034 2071.75 85554.00 0.00
P 2173 2247.00 83365.00 83186.18
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 1296 4075.50 210599.78 210641.26
T 1 1.25 46.25 0.00
404 677.00 55127.60 403.64
Other 0 0.00 0.00 0.00
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Total 6230 9410.00 448160.63 294231.08