CMS/EIP Fiscal Report Center: 07
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 908 2703.00 99890.75 36.96
Subtotal (Total Children Is Unduplicated) 908 2703.00 99890.75 36.96
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 6.00 450.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 16.00 1200.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 10.00 555.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 20 35.00 2625.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 9 18.00 1350.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 8.50 637.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 58 108.00 5994.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 87 226.50 16912.50 74.67
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 2 2.00 145.56 72.78
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 5 5.00 242.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 4 4.00 194.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 37 37.00 1850.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 9 9.00 436.50 48.50
Subtotal (Total Children Is Unduplicated) 169 486.00 32667.56 67.22
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 338 2161.75 108087.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 37 261.50 17750.62 67.88
PHY-97110-PT SESSION BY LICENSED PT 21 152.75 10368.67 67.88
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 3 3.00 150.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 43 214.25 14543.29 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 1 0.50 6.60 13.20
Subtotal (Total Children Is Unduplicated) 406 2793.75 150906.68 54.02
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Total 5982.75 283464.99 47.38
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Number of Children (Unduplicated) With at Least One Service 963
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Center 07
Flag Claims Units Chgs Paid
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R 232 148.00 5476.00 0.00
U 0 0.00 0.00 0.00
B 4023 2618.75 105840.31 0.00
P 346 200.00 7374.25 7374.25
D 0 0.00 0.00 0.00
S 5 5.25 194.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
1139 3010.75 164580.18 0.00
Other 0 0.00 0.00 0.00
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Total 5745 5982.75 283464.99 7374.25