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: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 1339 3389.50 125411.50 37.00
Subtotal (Total Children Is Unduplicated) 1339 3389.50 125411.50 37.00
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 7.50 525.00 70.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 13 21.00 1575.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 15 21.50 1193.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 24 28.75 2117.50 73.65
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 73 96.00 5297.25 55.18
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 74 96.50 7237.50 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) 164 282.25 18505.50 65.56
----------------------------------------------------------------------------------------------------------------
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 134 537.00 26766.63 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 55 335.75 22788.30 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) 263 1695.50 104214.18 61.47
----------------------------------------------------------------------------------------------------------------
Total 5367.25 248131.18 46.23
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1354
----------------------------------------------------------------------------------------------------------------
Center 01
Flag Claims Units Chgs Paid
-------------------------------------------------
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 1085 687.75 25474.50 0.00
H 5 6.00 345.75 0.00
T 132 166.50 10938.75 10938.75
737 1693.25 101211.28 0.00
Other 4480 2813.75 110160.90 0.00
-------------------------------------------------
Total 6439 5367.25 248131.18 10938.75