CMS/EIP Fiscal Report Center: 01
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 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 1133 2888.00 106856.00 37.00
Subtotal (Total Children Is Unduplicated) 1133 2888.00 106856.00 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 2.50 187.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 7 15.00 1125.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 12 18.50 1026.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 20 23.75 1742.50 73.37
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 56 74.00 4076.25 55.08
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 55 73.50 5512.50 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 3 3.00 145.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 6 6.00 291.00 48.50
Subtotal (Total Children Is Unduplicated) 125 218.25 14230.50 65.20
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 5.00 120.00 24.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 129 525.50 26191.63 49.84
OCCT-97530-OT SESSION BY LICENSED OT 29 137.50 9333.50 67.88
OCCT-97530HM-OT SESSION BY OT ASST 3 15.00 814.80 54.32
PHY-97110-PT SESSION BY LICENSED PT 54 330.75 22448.90 67.87
PHY-97110HM-PT SESSION BY PT ASST 3 51.75 2811.06 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 121 613.50 41579.89 67.77
Subtotal (Total Children Is Unduplicated) 257 1679.00 103299.78 61.52
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Total 4785.25 224386.28 46.89
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Number of Children (Unduplicated) With at Least One Service 1147
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Center 01
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 0 0.00 0.00 0.00
P 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 971 594.50 22024.25 0.00
H 3 3.00 150.00 0.00
T 103 135.00 8831.00 8831.00
701 1655.25 99097.63 0.00
Other 3846 2397.50 94283.40 0.00
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Total 5624 4785.25 224386.28 8831.00