CMS/EIP Fiscal Report Center: 52
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 354 904.50 33198.25 36.70
Subtotal (Total Children Is Unduplicated) 354 904.50 33198.25 36.70
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 4.50 337.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 3.00 225.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.50 112.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 6.00 333.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 22 34.50 2587.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 13 17.50 1312.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 44 64.50 3579.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 9.00 675.00 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 14 14.00 679.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 3 3.00 145.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 9 9.00 436.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 7 7.00 350.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 11 11.00 533.50 48.50
Subtotal (Total Children Is Unduplicated) 91 184.50 11307.25 61.29
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 54 266.00 13300.00 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 1 6.00 300.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 46 350.50 23791.94 67.88
PHY-97110-PT SESSION BY LICENSED PT 60 322.50 21891.30 67.88
PHY-97110HM-PT SESSION BY PT ASST 2 5.75 312.34 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 88 451.75 30664.79 67.88
Subtotal (Total Children Is Unduplicated) 161 1402.50 90260.37 64.36
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Total 2491.50 134765.87 54.09
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Number of Children (Unduplicated) With at Least One Service 359
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Center 52
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 1848 1144.00 49087.67 0.00
P 141 72.00 2664.00 2664.00
D 0 0.00 0.00 0.00
S 1 0.25 9.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
544 1275.25 83004.95 0.00
Other 0 0.00 0.00 0.00
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Total 2534 2491.50 134765.87 2664.00