CMS/EIP Fiscal Report Center: 07
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 943 3048.00 112766.75 37.00
Subtotal (Total Children Is Unduplicated) 943 3048.00 112766.75 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.50 112.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 10.00 750.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 6.00 333.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 22 42.50 3187.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 9.50 712.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 7.50 562.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 70 134.50 7464.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 131 370.00 27750.00 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 6 7.00 339.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 44 44.00 2200.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 12 12.00 582.00 48.50
Subtotal (Total Children Is Unduplicated) 211 647.50 44139.75 68.17
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 354 2552.25 127612.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 32 250.25 16986.97 67.88
PHY-97110-PT SESSION BY LICENSED PT 26 140.75 9554.11 67.88
SENS-V5264-EARMOLD 1 2.00 37.44 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 50 366.25 24861.05 67.88
Subtotal (Total Children Is Unduplicated) 422 3311.50 179052.07 54.07
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Total 7007.00 335958.57 47.95
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Number of Children (Unduplicated) With at Least One Service 998
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Center 07
Flag Claims Units Chgs Paid
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R 3 2.00 74.00 0.00
U 0 0.00 0.00 0.00
B 92 53.50 2049.50 0.00
P 5031 3288.50 134347.50 134235.00
D 0 0.00 0.00 0.00
S 101 57.00 2099.75 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
1261 3606.00 197387.82 0.00
Other 0 0.00 0.00 0.00
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Total 6488 7007.00 335958.57 134235.00