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: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 1214 4591.50 169848.50 36.99
Subtotal (Total Children Is Unduplicated) 1214 4591.50 169848.50 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 14 12.50 937.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 31 33.00 1831.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 64 34.00 2550.00 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 70 48.00 3600.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 196 177.00 9769.50 55.19
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 68 67.00 5025.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 131 131.00 24235.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.00 275.00 275.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 29 29.00 3045.00 105.00
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) 348 610.50 55321.50 90.62
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 571 4880.50 244025.00 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) 639 5862.25 309909.21 52.87
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Total 11064.25 535079.21 48.36
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Number of Children (Unduplicated) With at Least One Service 1312
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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 1799 1907.50 75726.75 0.00
P 2979 2996.50 125341.25 117333.63
D 0 0.00 0.00 0.00
S 1 2.00 74.00 0.00
H 1690 5541.00 287853.58 287852.92
T 0 0.00 0.00 0.00
419 617.25 46083.63 300.00
Other 0 0.00 0.00 0.00
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Total 6888 11064.25 535079.21 405486.55