CMS/EIP Fiscal Report Center: 51
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 582 2830.25 104700.75 36.99
Subtotal (Total Children Is Unduplicated) 582 2830.25 104700.75 36.99
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 3.00 225.00 75.00
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 4.50 337.50 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 58 70.50 5287.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 16 16.50 1237.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 11 14.00 1050.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 9 14.50 804.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 89 100.50 7537.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 5 5.00 202.50 40.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 3.00 145.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 5 5.00 242.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 10 10.00 485.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 13 13.00 630.50 48.50
Subtotal (Total Children Is Unduplicated) 133 261.00 18298.25 70.11
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 3 8.00 9304.12 1163.02
AUD-92630-AUD REHAB PRELING HEARING LOSS 1 3.00 206.58 68.86
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 203 1224.25 61212.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 57 263.75 17771.59 67.38
OCCT-97530HM-OT SESSION BY OT ASST 4 8.50 461.72 54.32
PHY-97110-PT SESSION BY LICENSED PT 61 361.50 24538.62 67.88
PHY-97110HM-PT SESSION BY PT ASST 16 95.50 5187.56 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 112 754.75 51232.43 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 1 6.50 85.80 13.20
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 3 26.25 1312.50 50.00
Subtotal (Total Children Is Unduplicated) 285 2752.00 171313.42 62.25
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Total 5843.25 294312.42 50.37
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Number of Children (Unduplicated) With at Least One Service 588
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Center 51
Flag Claims Units Chgs Paid
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R 19 20.00 740.00 0.00
U 0 0.00 0.00 0.00
B 3886 2838.50 105879.75 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
1254 2984.00 187664.92 0.00
Other 1 0.75 27.75 0.00
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Total 5160 5843.25 294312.42 0.00