CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/17/2009 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 993 2340.50 86589.25 37.00
Subtotal (Total Children Is Unduplicated) 993 2340.50 86589.25 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.00 75.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 3.50 194.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 39 53.00 3908.50 73.75
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 25 49.50 3712.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 63 91.50 5073.25 55.45
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 31 40.50 3037.50 75.00
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 5 5.00 242.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 3 3.00 145.50 48.50
Subtotal (Total Children Is Unduplicated) 117 248.00 16437.50 66.28
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 95 488.00 24400.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 8 16.50 1118.08 67.76
OCCT-97530HM-OT SESSION BY OT ASST 2 10.00 543.20 54.32
PHY-97110-PT SESSION BY LICENSED PT 29 131.25 8873.37 67.61
PHY-97110HM-PT SESSION BY PT ASST 3 22.00 1195.04 54.32
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 5.00 250.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 109 570.25 38462.89 67.45
SPL-92508-GROUP SPL SESSION PER CHILD 2 3.25 42.90 13.20
Subtotal (Total Children Is Unduplicated) 207 1246.25 74885.48 60.09
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Total 3834.75 177912.23 46.39
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Number of Children (Unduplicated) With at Least One Service 1031
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Center 01
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 776 509.25 18842.25 0.00
P 4 5.00 222.00 0.00
D 161 129.00 4786.00 0.00
S 416 328.25 12145.25 0.00
H 6 7.50 458.25 0.00
T 1 0.50 18.50 0.00
564 1301.25 78232.32 0.00
Other 2431 1554.00 63207.66 0.00
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Total 4359 3834.75 177912.23 0.00