CMS/EIP Fiscal Report Center: 55
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 370 1008.75 36907.50 36.59
Subtotal (Total Children Is Unduplicated) 370 1008.75 36907.50 36.59
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.00 225.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.50 112.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.50 83.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 26 44.50 3337.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 20 34.50 2587.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 7.00 525.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 26 45.00 2497.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 34 51.00 3825.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 2 2.00 97.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 4 4.00 194.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.00 97.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 16 16.00 776.00 48.50
Subtotal (Total Children Is Unduplicated) 86 213.00 14405.75 67.63
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 47 293.00 14650.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 41 218.25 14814.81 67.88
OCCT-97530HM-OT SESSION BY OT ASST 6 28.00 1520.96 54.32
PHY-97110-PT SESSION BY LICENSED PT 30 105.25 7144.37 67.88
PHY-97110HM-PT SESSION BY PT ASST 7 20.50 1113.56 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 146 732.75 49722.10 67.86
SPL-92508-GROUP SPL SESSION PER CHILD 1 2.00 26.40 13.20
Subtotal (Total Children Is Unduplicated) 215 1399.75 88992.20 63.58
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Total 2621.50 140305.45 53.52
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Number of Children (Unduplicated) With at Least One Service 438
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Center 55
Flag Claims Units Chgs Paid
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R 20 22.25 824.75 0.00
U 0 0.00 0.00 0.00
B 272 229.25 8251.00 0.00
P 871 801.75 31473.25 31464.00
D 0 0.00 0.00 0.00
S 2 2.50 92.50 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
1974 1565.75 99663.95 0.00
Other 0 0.00 0.00 0.00
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Total 3139 2621.50 140305.45 31464.00