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: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 369 1258.75 46573.75 37.00
Subtotal (Total Children Is Unduplicated) 369 1258.75 46573.75 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 8 8.50 637.50 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 11 11.50 862.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 10 13.50 749.25 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 13 13.00 946.14 72.78
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 7 7.00 351.05 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 14 14.00 700.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 7 7.00 339.50 48.50
Subtotal (Total Children Is Unduplicated) 69 101.50 6213.44 61.22
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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 46 167.00 11335.96 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 79 308.00 20907.04 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) 143 1028.75 64534.67 62.73
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Total 2389.00 117321.86 49.11
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Number of Children (Unduplicated) With at Least One Service 373
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Center 05
Flag Claims Units Chgs Paid
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R 32 32.00 1960.06 0.00
U 0 0.00 0.00 0.00
B 2315 1257.00 46509.00 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
1708 1100.00 68852.80 0.00
Other 0 0.00 0.00 0.00
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Total 4055 2389.00 117321.86 0.00