CMS/EIP Fiscal Report Center: 10
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 1364 4785.00 177045.00 37.00
Subtotal (Total Children Is Unduplicated) 1364 4785.00 177045.00 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 13 22.50 1687.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 8.50 637.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 13 22.50 1687.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.00 300.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 16 30.50 1692.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 119 207.00 15525.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 90 149.50 11212.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 86 141.50 10612.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 174 311.50 17288.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 99 110.00 8250.00 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 9 9.00 436.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 3 3.00 145.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 7 7.00 339.50 48.50
Subtotal (Total Children Is Unduplicated) 308 1026.50 69815.00 68.01
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 10 34.00 850.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 117 1076.25 53812.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 103 390.25 26483.39 67.86
OCCT-97530HM-OT SESSION BY OT ASST 3 8.00 434.56 54.32
PHY-97110-PT SESSION BY LICENSED PT 203 675.25 45835.97 67.88
PHY-97110HM-PT SESSION BY PT ASST 1 0.50 27.16 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 162 540.00 36655.20 67.88
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 3 5.50 298.76 54.32
Subtotal (Total Children Is Unduplicated) 398 2729.75 164397.54 60.22
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Total 8541.25 411257.54 48.15
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Number of Children (Unduplicated) With at Least One Service 1392
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Center 10
Flag Claims Units Chgs Paid
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R 684 438.00 17217.75 0.00
U 0 0.00 0.00 0.00
B 6743 4507.50 180490.75 0.00
P 704 777.75 45667.75 45612.25
D 0 0.00 0.00 0.00
S 128 69.25 2562.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
1281 2748.75 165319.04 0.00
Other 0 0.00 0.00 0.00
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Total 9540 8541.25 411257.54 45612.25