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: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 519 1990.75 73639.25 36.99
Subtotal (Total Children Is Unduplicated) 519 1990.75 73639.25 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 25 27.00 2025.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 12 13.50 1012.50 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 6 8.50 471.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 50 56.00 4137.50 73.88
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 16 16.00 776.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 9 10.00 485.00 48.50
Subtotal (Total Children Is Unduplicated) 96 159.00 10546.05 66.33
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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 130 780.75 38841.50 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 69 367.25 24874.25 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) 204 1950.00 115627.33 59.30
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Total 4099.75 199812.63 48.74
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Number of Children (Unduplicated) With at Least One Service 533
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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 3137 2067.75 78147.51 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
821 2016.50 120626.89 0.00
Other 0 0.00 0.00 0.00
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Total 3962 4099.75 199812.63 801.85