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: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 969 2901.50 107235.25 36.96
Subtotal (Total Children Is Unduplicated) 969 2901.50 107235.25 36.96
----------------------------------------------------------------------------------------------------------------
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 6 20.00 1500.00 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 21 37.00 2775.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 10 20.00 1500.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 12.50 937.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 69 128.00 7104.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 102 261.50 19537.50 74.71
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 45 45.00 2250.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 10 10.00 485.00 48.50
Subtotal (Total Children Is Unduplicated) 196 562.00 37751.06 67.17
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 339 2162.00 108100.00 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) 407 2794.00 150919.18 54.02
----------------------------------------------------------------------------------------------------------------
Total 6257.50 295905.49 47.29
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1024
----------------------------------------------------------------------------------------------------------------
Center 07
Flag Claims Units Chgs Paid
-------------------------------------------------
R 244 157.00 5809.00 0.00
U 0 0.00 0.00 0.00
B 4277 2844.00 115340.81 0.00
P 355 208.50 7916.75 7916.75
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
1161 3042.75 166644.68 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 6042 6257.50 295905.49 7916.75