CMS/EIP Fiscal Report Center: 05
Services beginning 01/01/2010 ending 03/31/2010 Date of Report:05/17/2010 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 442 1580.25 58469.25 37.00
Subtotal (Total Children Is Unduplicated) 442 1580.25 58469.25 37.00
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.00 150.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 5.50 305.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 7 11.50 862.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.00 150.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 8.00 600.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 27 48.50 2691.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 4.00 300.00 75.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 6 6.00 436.68 72.78
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 6 6.00 300.90 50.15
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 3.00 145.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.00 97.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 12 12.00 600.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 3 3.00 145.50 48.50
Subtotal (Total Children Is Unduplicated) 62 113.50 6785.08 59.78
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 120 692.00 34600.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 23 41.25 2800.05 67.88
OCCT-97530HM-OT SESSION BY OT ASST 1 1.50 81.48 54.32
PHY-97110-PT SESSION BY LICENSED PT 40 88.75 6024.35 67.88
PHY-97110HM-PT SESSION BY PT ASST 1 0.50 27.16 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 67 146.00 9910.48 67.88
Subtotal (Total Children Is Unduplicated) 178 970.00 53443.52 55.10
----------------------------------------------------------------------------------------------------------------
Total 2663.75 118697.85 44.56
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 448
----------------------------------------------------------------------------------------------------------------
Center 05
Flag Claims Units Chgs Paid
-------------------------------------------------
R 78 42.25 1563.25 0.00
U 0 0.00 0.00 0.00
B 2595 1428.50 52900.75 0.00
P 0 0.00 0.00 0.00
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
1432 1193.00 64233.85 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 4105 2663.75 118697.85 0.00