CMS/EIP Fiscal Report Center: 09
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 933 2750.00 101687.25 36.98
Subtotal (Total Children Is Unduplicated) 933 2750.00 101687.25 36.98
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 22 36.00 2700.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 5.50 412.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.00 150.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 12 20.50 1537.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 10 16.00 888.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 163 243.50 18225.00 74.85
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 28 46.50 3487.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 26 45.00 3375.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 151 244.00 13486.50 55.27
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 28 41.00 3075.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 5 5.00 242.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 3.00 145.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.00 97.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 2 2.00 97.00 48.50
Subtotal (Total Children Is Unduplicated) 231 712.00 47919.00 67.30
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 296 2015.50 100775.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 141 973.25 66064.21 67.88
OCCT-97530HM-OT SESSION BY OT ASST 1 5.50 298.76 54.32
PHY-97110-PT SESSION BY LICENSED PT 140 843.50 57256.78 67.88
PHY-97110HM-PT SESSION BY PT ASST 8 52.00 2824.64 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 217 1584.75 107572.83 67.88
Subtotal (Total Children Is Unduplicated) 570 5474.50 334792.22 61.15
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Total 8936.50 484398.47 54.20
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Number of Children (Unduplicated) With at Least One Service 1052
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Center 09
Flag Claims Units Chgs Paid
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R 4 5.00 185.00 0.00
U 0 0.00 0.00 0.00
B 4065 3617.25 159174.11 0.00
P 84 108.50 6811.25 6810.75
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 1 1.00 50.00 50.00
T 0 0.00 0.00 0.00
1877 5204.75 318178.11 0.00
Other 0 0.00 0.00 0.00
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Total 6031 8936.50 484398.47 6860.75