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: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 1881 15412.8 570244.00 37.00
Subtotal (Total Children Is Unduplicated) 1881 15412.8 570244.00 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 4.00 300.00 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 5 4.50 337.50 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 38 38.50 2136.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 65 43.50 3262.50 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 68 53.50 4012.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 206 203.00 11266.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 72 75.00 5625.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 285 287.00 53045.50 184.83
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 10 10.00 2750.00 275.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 98 113.00 11865.00 105.00
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) 640 1034.50 105846.75 102.32
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 639 11286.5 564125.00 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) 715 12940.8 675917.91 52.23
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Total 29388.00 1352008.66 46.01
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Number of Children (Unduplicated) With at Least One Service 1903
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Center 04
Flag Claims Units Chgs Paid
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R 14 23.50 869.50 0.00
U 0 0.00 0.00 0.00
B 3457 3318.75 129478.25 0.00
P 13739 12625.50 496257.01 475256.38
D 65 79.75 4539.84 1388.09
S 0 0.00 0.00 0.00
H 3532 11713.50 592917.22 593617.13
T 0 0.00 0.00 0.00
892 1627.00 127946.84 0.00
Other 0 0.00 0.00 0.00
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Total 21699 29388.00 1352008.66 1070261.60