CMS/EIP Fiscal Report Center: 04
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 965 3628.25 134245.25 37.00
Subtotal (Total Children Is Unduplicated) 965 3628.25 134245.25 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 1.00 75.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 3.00 225.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 14 13.50 1012.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 16 17.00 943.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 14 11.00 825.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 2.00 150.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 22 15.50 1162.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 76 74.00 4107.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 29 30.50 2287.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 73 73.00 13360.50 183.02
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 4 4.00 1100.00 275.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 28 28.00 2940.00 105.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 15 15.00 727.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 3.00 145.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 14 14.00 679.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 3 3.00 145.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 31 32.00 1552.00 48.50
Subtotal (Total Children Is Unduplicated) 199 339.50 31438.00 92.60
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 373 3026.00 151250.00 49.98
OCCT-97530-OT SESSION BY LICENSED OT 31 128.25 8705.61 67.88
OCCT-97530HM-OT SESSION BY OT ASST 2 5.00 271.60 54.32
PHY-97110-PT SESSION BY LICENSED PT 49 199.75 13559.03 67.88
PHY-97110HM-PT SESSION BY PT ASST 2 3.00 162.96 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 28 94.00 6380.72 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.00 13.20 13.20
Subtotal (Total Children Is Unduplicated) 428 3457.00 180343.12 52.17
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Total 7424.75 346026.37 46.60
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Number of Children (Unduplicated) With at Least One Service 1012
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Center 04
Flag Claims Units Chgs Paid
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R 22 48.50 1794.50 0.00
U 0 0.00 0.00 0.00
B 3800 3588.75 133886.25 0.00
P 122 115.00 8811.26 7595.74
D 39 41.50 2599.44 283.94
S 0 0.00 0.00 0.00
H 940 3141.50 159075.90 159543.60
T 0 0.00 0.00 0.00
328 489.50 39859.02 0.00
Other 0 0.00 0.00 0.00
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Total 5251 7424.75 346026.37 167423.28