CMS/EIP Fiscal Report Center: 09
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 790 2188.50 80872.75 36.95
Subtotal (Total Children Is Unduplicated) 790 2188.50 80872.75 36.95
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Screening, Eval, and Assessment,Class #02
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 1.00 119.60 119.60
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 28 42.50 3187.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 6.00 450.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 13 16.00 1200.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 10 18.00 1350.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 14 21.00 1165.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 131 197.50 14812.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 26 47.50 3562.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 66 94.00 7050.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 95 152.00 8436.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 17 21.00 1575.00 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 3.00 145.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.00 48.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 3.00 145.50 48.50
Subtotal (Total Children Is Unduplicated) 211 623.50 43248.10 69.36
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 230 1548.00 77400.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 127 842.75 57205.87 67.88
OCCT-97530HM-OT SESSION BY OT ASST 1 4.75 258.02 54.32
PHY-97110-PT SESSION BY LICENSED PT 133 773.75 52522.15 67.88
PHY-97110HM-PT SESSION BY PT ASST 9 43.75 2376.50 54.32
SENS-V5264-EARMOLD 1 2.00 37.44 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 146 970.00 65843.60 67.88
Subtotal (Total Children Is Unduplicated) 470 4185.00 255643.58 61.09
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Total 6997.00 379764.43 54.28
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Number of Children (Unduplicated) With at Least One Service 914
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Center 09
Flag Claims Units Chgs Paid
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R 107 70.50 2691.00 0.00
U 0 0.00 0.00 0.00
B 2955 2470.00 113453.66 46.25
P 686 625.50 29252.68 112284.18
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
1487 3831.00 234367.09 0.00
Other 0 0.00 0.00 0.00
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Total 5235 6997.00 379764.43 112330.43