CMS/EIP Fiscal Report Center: 04
Services beginning 04/01/2010 ending 06/30/2010 Date of Report:08/18/2010 Page: 1
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
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 1074 4103.75 151801.75 36.99
Subtotal (Total Children Is Unduplicated) 1074 4103.75 151801.75 36.99
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 3.00 225.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 2.50 187.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 7 6.00 450.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 12 11.00 825.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 30 32.00 1776.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 52 28.00 2100.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 1.50 38.00 25.33
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 55 38.00 2850.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 154 141.50 7799.25 55.12
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 57 57.50 4312.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 104 104.00 19240.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.00 275.00 275.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 27 27.00 2835.00 105.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 4 4.00 194.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 14 14.00 679.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 5 5.00 242.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 12 12.00 582.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 30 30.00 1455.00 48.50
Subtotal (Total Children Is Unduplicated) 292 518.00 46065.75 88.93
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 568 4858.50 242925.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 60 337.50 22909.50 67.88
PHY-97110-PT SESSION BY LICENSED PT 49 238.00 16155.44 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 82 380.75 25845.31 67.88
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 5 15.50 841.96 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 2 10.00 132.00 13.20
Subtotal (Total Children Is Unduplicated) 636 5840.25 308809.21 52.88
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Total 10462.00 506676.71 48.43
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Number of Children (Unduplicated) With at Least One Service 1169
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Center 04
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 1567 1654.00 65385.00 0.00
P 2664 2701.00 111756.75 105377.65
D 0 0.00 0.00 0.00
S 1 2.00 74.00 0.00
H 1684 5519.00 286753.58 286752.92
T 0 0.00 0.00 0.00
392 586.00 42707.38 300.00
Other 0 0.00 0.00 0.00
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Total 6308 10462.00 506676.71 392430.57