CMS/EIP Fiscal Report Center: 51
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 482 1855.00 68616.50 36.99
Subtotal (Total Children Is Unduplicated) 482 1855.00 68616.50 36.99
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Screening, Eval, and Assessment,Class #02
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.00 10.80 10.80
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.00 75.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.50 112.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 5.00 375.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 22 24.00 1800.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 11 12.50 937.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 4.50 337.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 5 7.50 416.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 43 49.00 3637.50 74.23
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 2 2.00 97.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 7 8.00 388.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 5 5.00 242.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 14 14.00 679.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 9 10.00 485.00 48.50
Subtotal (Total Children Is Unduplicated) 85 145.00 9593.55 66.16
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 3 14.00 1163.84 83.13
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 2 13.00 954.46 73.42
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 129 779.75 38791.50 49.75
OCCT-97530-OT SESSION BY LICENSED OT 49 302.00 20499.76 67.88
OCCT-97530HM-OT SESSION BY OT ASST 15 65.25 3544.38 54.32
PHY-97110-PT SESSION BY LICENSED PT 61 302.50 20486.20 67.72
PHY-97110HM-PT SESSION BY PT ASST 15 91.00 4889.80 53.73
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 67 356.25 24127.57 67.73
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 4.50 244.44 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 4 9.75 128.70 13.20
Subtotal (Total Children Is Unduplicated) 201 1938.00 114830.65 59.25
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Total 3938.00 193040.70 49.02
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Number of Children (Unduplicated) With at Least One Service 494
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Center 51
Flag Claims Units Chgs Paid
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R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 2949 1928.00 72824.76 0.00
P 2 13.00 869.73 801.85
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 1 2.00 150.00 0.00
T 1 0.50 18.50 0.00
806 1994.50 119177.71 0.00
Other 0 0.00 0.00 0.00
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Total 3759 3938.00 193040.70 801.85