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: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 1074 3093.75 114406.00 36.98
Subtotal (Total Children Is Unduplicated) 1074 3093.75 114406.00 36.98
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 27 44.00 3300.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 7.00 525.00 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 14 23.50 1762.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 14 22.50 1248.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 266 380.50 28500.00 74.90
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 47 77.50 5812.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 46 78.50 5887.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 252 394.50 21839.25 55.36
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 44 59.00 4425.00 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) 365 1101.00 74032.50 67.24
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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 9669.25 523230.72 54.11
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Number of Children (Unduplicated) With at Least One Service 1216
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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 4562 4288.00 194144.86 0.00
P 117 147.00 9542.75 9542.25
D 0 0.00 0.00 0.00
S 2 3.00 195.75 0.00
H 1 1.00 50.00 50.00
T 0 0.00 0.00 0.00
1888 5225.25 319112.36 0.00
Other 0 0.00 0.00 0.00
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Total 6574 9669.25 523230.72 9592.25