CMS/EIP Fiscal Report Center: 09
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 896 2319.00 85803.00 37.00
Subtotal (Total Children Is Unduplicated) 896 2319.00 85803.00 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 41 66.00 4950.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 6 11.00 825.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 6.00 450.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 16 31.00 2325.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 28 42.00 2331.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 203 278.00 20850.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 30 49.00 3675.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 52 75.50 5662.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 188 281.00 15595.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 24 29.00 2175.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 6 6.00 291.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 2 2.00 97.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 5 5.00 242.50 48.50
Subtotal (Total Children Is Unduplicated) 312 882.50 59518.00 67.44
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 252 1725.25 86262.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 137 919.00 62381.72 67.88
OCCT-97530HM-OT SESSION BY OT ASST 1 11.50 624.68 54.32
PHY-97110-PT SESSION BY LICENSED PT 148 837.00 56815.56 67.88
PHY-97110HM-PT SESSION BY PT ASST 9 57.00 3096.24 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 184 1086.00 73717.68 67.88
Subtotal (Total Children Is Unduplicated) 520 4635.75 282898.38 61.03
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Total 7837.25 428219.38 54.64
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Number of Children (Unduplicated) With at Least One Service 1065
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Center 09
Flag Claims Units Chgs Paid
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R 8 6.75 286.75 0.00
U 0 0.00 0.00 0.00
B 3189 2811.50 126879.29 0.00
P 524 588.25 31588.55 31588.55
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 1 1.00 75.00 75.00
T 0 0.00 0.00 0.00
1671 4427.75 269315.79 0.00
Other 3 2.00 74.00 0.00
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Total 5396 7837.25 428219.38 31663.55