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: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 1087 4083.50 151071.00 37.00
Subtotal (Total Children Is Unduplicated) 1087 4083.50 151071.00 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 1.50 112.50 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 17 18.00 999.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 18 13.50 1012.50 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 30 22.00 1650.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 92 88.00 4884.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 33 35.00 2625.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 93 93.00 17060.50 183.45
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) 234 388.50 37020.50 95.29
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 374 3035.00 151700.00 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) 429 3466.00 180793.12 52.16
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Total 7938.00 368884.62 46.47
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Number of Children (Unduplicated) With at Least One Service 1134
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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 4203 4045.00 150879.50 0.00
P 148 135.00 10563.26 8954.83
D 45 47.50 2932.44 283.94
S 0 0.00 0.00 0.00
H 943 3150.50 159525.90 159993.60
T 0 0.00 0.00 0.00
347 511.50 43189.02 0.00
Other 0 0.00 0.00 0.00
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Total 5708 7938.00 368884.62 169232.37