CMS/EIP Fiscal Report Center: 05
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 300 1003.75 37138.75 37.00
Subtotal (Total Children Is Unduplicated) 300 1003.75 37138.75 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 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 3 3.00 225.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 7 7.00 525.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 4.00 300.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 7.50 562.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 8 11.00 610.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 6 6.00 436.68 72.78
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 1 1.00 50.15 50.15
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 3 3.00 145.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 4 4.00 194.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 7 7.00 339.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 3 3.00 150.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 7 7.00 339.50 48.50
Subtotal (Total Children Is Unduplicated) 47 69.50 4301.83 61.90
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 64 251.25 12562.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 45 165.00 11200.20 67.88
OCCT-97530HM-OT SESSION BY OT ASST 5 21.75 1181.46 54.32
PHY-97110-PT SESSION BY LICENSED PT 67 250.75 17020.91 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 78 307.00 20839.16 67.88
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 10 27.50 1493.80 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 1 2.50 33.00 13.20
Subtotal (Total Children Is Unduplicated) 142 1025.75 64331.03 62.72
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Total 2099.00 105771.61 50.39
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Number of Children (Unduplicated) With at Least One Service 303
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Center 05
Flag Claims Units Chgs Paid
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R 19 19.00 1264.05 0.00
U 0 0.00 0.00 0.00
B 1907 1002.00 37074.00 0.00
P 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
1684 1078.00 67433.56 0.00
Other 0 0.00 0.00 0.00
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Total 3610 2099.00 105771.61 0.00