CMS/EIP Fiscal Report Center: 55
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 337 916.75 33901.25 36.98
Subtotal (Total Children Is Unduplicated) 337 916.75 33901.25 36.98
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 5.50 412.50 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 2 4.00 222.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 18 33.00 2400.00 72.73
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 15 27.50 2062.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 6.00 450.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 14 25.00 1387.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 16 24.00 1800.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.00 48.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 3.00 145.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 5 5.00 242.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 6 6.00 291.00 48.50
Subtotal (Total Children Is Unduplicated) 55 141.50 9574.50 67.66
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 16 74.00 3700.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 55 225.50 15252.70 67.64
OCCT-97530HM-OT SESSION BY OT ASST 5 33.00 1792.56 54.32
PHY-97110-PT SESSION BY LICENSED PT 31 83.00 5634.04 67.88
PHY-97110HM-PT SESSION BY PT ASST 8 11.50 624.68 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 67 294.50 19990.66 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.00 13.20 13.20
Subtotal (Total Children Is Unduplicated) 115 722.50 47007.84 65.06
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Total 1780.75 90483.59 50.81
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Number of Children (Unduplicated) With at Least One Service 375
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Center 55
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 129 154.75 6181.75 0.00
P 745 738.75 27828.25 27828.25
D 0 0.00 0.00 0.00
S 11 12.75 471.75 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
1085 874.50 56001.84 0.00
Other 0 0.00 0.00 0.00
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Total 1970 1780.75 90483.59 27828.25