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: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 870 2338.00 86404.25 36.96
Subtotal (Total Children Is Unduplicated) 870 2338.00 86404.25 36.96
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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 32 46.50 3487.50 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 18 22.00 1650.00 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 16 23.00 1276.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 191 271.50 20362.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 35 63.50 4762.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 103 136.50 10237.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 140 211.00 11710.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 27 33.00 2475.00 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) 298 839.00 58221.10 69.39
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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 7362.00 400268.93 54.37
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Number of Children (Unduplicated) With at Least One Service 1025
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Center 09
Flag Claims Units Chgs Paid
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R 117 85.75 3388.25 0.00
U 0 0.00 0.00 0.00
B 3160 2720.00 127245.16 46.25
P 753 706.50 34257.18 117288.68
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
1501 3849.75 235378.34 0.00
Other 0 0.00 0.00 0.00
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Total 5531 7362.00 400268.93 117334.93