CMS/EIP Fiscal Report Center: 01
Services beginning 04/01/2010 ending 06/30/2010 Date of Report:08/18/2010 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 1892 5649.00 208689.25 36.94
Subtotal (Total Children Is Unduplicated) 1892 5649.00 208689.25 36.94
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 28 40.00 3000.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.00 75.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 4.00 300.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 16 27.50 2062.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 15 22.50 1248.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 247 355.00 26587.50 74.89
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 23 33.50 2512.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 53 72.50 5437.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 197 267.50 14845.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 127 180.00 13500.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.00 48.50 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
PSTH-97001-EVAL BY LICENSED PT, INITIAL 5 6.00 291.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 12 12.00 582.00 48.50
Subtotal (Total Children Is Unduplicated) 374 1025.50 70636.50 68.88
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 7 38.00 9475.65 249.36
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 3.00 90.00 30.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 401 3016.00 150532.50 49.91
OCCT-97530-OT SESSION BY LICENSED OT 9 41.25 2800.05 67.88
OCCT-97530HM-OT SESSION BY OT ASST 1 3.00 162.96 54.32
PHY-97110-PT SESSION BY LICENSED PT 91 509.25 34564.01 67.87
PHY-97110HM-PT SESSION BY PT ASST 2 3.00 162.96 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 125 590.75 40088.38 67.86
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 2 7.50 407.40 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 3 9.00 118.80 13.20
Subtotal (Total Children Is Unduplicated) 562 4220.75 238402.71 56.48
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Total 10895.25 517728.46 47.52
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Number of Children (Unduplicated) With at Least One Service 1938
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Center 01
Flag Claims Units Chgs Paid
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R 16 8.25 374.13 0.00
U 0 0.00 0.00 0.00
B 5437 3823.75 153010.00 9.25
P 2236 1540.75 58035.06 57507.75
D 73 45.50 1683.50 0.00
S 1059 841.25 36427.75 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
1128 2794.00 152797.68 1100.00
Other 1717 1841.75 115400.34 0.00
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Total 11666 10895.25 517728.46 58617.00