CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2008 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 1564 13439.3 497243.00 37.00
Subtotal (Total Children Is Unduplicated) 1564 13439.3 497243.00 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 3.50 262.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 0.50 37.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 3.50 262.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 25 24.50 1837.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 33 33.50 1859.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 45 31.00 2325.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 3.50 262.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 51 41.00 3075.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 160 160.50 8907.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 62 65.00 4875.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 216 217.00 40000.50 184.33
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 10 10.00 2750.00 275.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 95 110.00 11550.00 105.00
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 6 6.00 960.00 160.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 26 27.00 1309.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 22 22.00 1067.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 34 40.00 1940.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 9 9.00 436.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 62 70.00 3395.00 48.50
Subtotal (Total Children Is Unduplicated) 525 877.50 87113.00 99.27
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 634 11263.0 562950.00 49.98
OCCT-97530-OT SESSION BY LICENSED OT 64 562.00 38148.56 67.88
OCCT-97530HM-OT SESSION BY OT ASST 4 8.00 434.56 54.32
PHY-97110-PT SESSION BY LICENSED PT 65 666.25 45225.05 67.88
PHY-97110HM-PT SESSION BY PT ASST 3 4.50 244.44 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 53 407.50 27661.10 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 3 6.00 79.20 13.20
Subtotal (Total Children Is Unduplicated) 710 12917.3 674742.91 52.24
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Total 27234.00 1259098.91 46.23
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Number of Children (Unduplicated) With at Least One Service 1581
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Center 04
Flag Claims Units Chgs Paid
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R 10 13.75 508.75 0.00
U 0 0.00 0.00 0.00
B 3087 2916.50 113118.75 0.00
P 12166 10958.00 428783.51 412096.67
D 57 71.75 4114.34 1351.09
S 0 0.00 0.00 0.00
H 3525 11691.50 591817.22 592517.13
T 0 0.00 0.00 0.00
850 1582.50 120756.34 0.00
Other 0 0.00 0.00 0.00
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Total 19695 27234.00 1259098.91 1005964.89