CMS/EIP Fiscal Report Center: 55
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 400 1197.50 44141.00 36.86
Subtotal (Total Children Is Unduplicated) 400 1197.50 44141.00 36.86
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Screening, Eval, and Assessment,Class #02
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 1 1.00 125.00 125.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 5.00 375.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.50 262.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 2.50 187.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 4.00 222.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 48 68.50 5137.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 21 37.00 2775.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 21 23.50 1762.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 30 49.50 2747.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 79 83.00 6225.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 3 3.00 145.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 7 7.00 339.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 2 2.00 97.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 10 11.00 533.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 19 19.00 921.50 48.50
Subtotal (Total Children Is Unduplicated) 148 319.50 21856.25 68.41
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 53 337.00 16850.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 52 324.50 22027.06 67.88
OCCT-97530HM-OT SESSION BY OT ASST 10 24.00 1303.68 54.32
PHY-97110-PT SESSION BY LICENSED PT 33 160.75 10911.71 67.88
PHY-97110HM-PT SESSION BY PT ASST 9 24.00 1303.68 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 157 923.00 62653.24 67.88
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 2 3.00 162.96 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 3 4.50 59.40 13.20
Subtotal (Total Children Is Unduplicated) 233 1800.75 115271.73 64.01
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Total 3317.75 181268.98 54.64
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Number of Children (Unduplicated) With at Least One Service 469
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Center 55
Flag Claims Units Chgs Paid
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R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 5 4.50 166.50 0.00
P 1361 1274.75 50248.25 50210.75
D 0 0.00 0.00 0.00
S 1 0.50 18.50 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
2573 2038.00 130835.73 0.00
Other 0 0.00 0.00 0.00
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Total 3940 3317.75 181268.98 50210.75