CMS/EIP Fiscal Report Center: 09
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 568 1768.75 65334.75 36.94
Subtotal (Total Children Is Unduplicated) 568 1768.75 65334.75 36.94
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 29 38.50 2887.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.00 150.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 18 21.00 1575.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 12 17.50 1312.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 14 21.00 1165.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 85 98.00 7350.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 22 41.00 3075.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 57 67.00 5025.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 100 146.00 8103.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 22 31.00 2325.00 75.00
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 2 2.00 97.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 3 3.00 145.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 6 6.00 300.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 194 495.00 33559.50 67.80
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 114 692.75 34637.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 88 513.75 34859.79 67.85
OCCT-97530HM-OT SESSION BY OT ASST 4 6.00 325.92 54.32
PHY-97110-PT SESSION BY LICENSED PT 113 648.25 44003.21 67.88
PHY-97110HM-PT SESSION BY PT ASST 10 67.75 3680.18 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 109 584.00 39641.92 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.00 13.20 13.20
Subtotal (Total Children Is Unduplicated) 306 2513.50 157161.72 62.53
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Total 4777.25 256055.97 53.60
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Number of Children (Unduplicated) With at Least One Service 690
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Center 09
Flag Claims Units Chgs Paid
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R 22 16.75 1023.55 0.00
U 0 0.00 0.00 0.00
B 527 527.75 29621.33 77.75
P 2426 2166.25 94813.26 121809.51
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 1 1.75 64.75 64.75
T 0 0.00 0.00 0.00
797 2063.50 130486.83 0.00
Other 2 1.25 46.25 0.00
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Total 3775 4777.25 256055.97 121952.01