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: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 1171 2798.75 103544.50 37.00
Subtotal (Total Children Is Unduplicated) 1171 2798.75 103544.50 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-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.00 150.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 2.50 187.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 7.00 388.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 50 65.50 4846.00 73.98
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 33 63.00 4725.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 82 115.50 6405.25 55.46
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 53 65.00 4875.00 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) 168 330.50 22088.75 66.83
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 101 501.00 25050.00 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 31 136.75 9246.71 67.62
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) 214 1264.75 75908.82 60.02
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Total 4394.00 201542.07 45.87
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Number of Children (Unduplicated) With at Least One Service 1213
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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 911 636.25 23541.25 0.00
P 4 5.00 222.00 0.00
D 204 170.75 6330.75 0.00
S 504 406.75 15049.75 0.00
H 7 8.50 533.25 0.00
T 1 0.50 18.50 0.00
605 1342.50 80588.41 0.00
Other 2731 1823.75 75258.16 0.00
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Total 4967 4394.00 201542.07 0.00