CMS/EIP Fiscal Report Center: 04
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 944 3317.50 122747.50 37.00
Subtotal (Total Children Is Unduplicated) 944 3317.50 122747.50 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 1.50 112.50 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 1 0.50 37.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 9 9.00 675.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 16 15.50 860.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 23 13.50 1012.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 1.50 112.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 21 15.50 1162.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 72 71.00 3940.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 19 19.00 1425.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 56 56.00 10360.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 3 3.00 825.00 275.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 36 36.00 3780.00 105.00
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 1 1.00 160.00 160.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 2 2.00 97.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 6 6.00 291.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 6 6.00 291.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 12 12.00 582.00 48.50
Subtotal (Total Children Is Unduplicated) 168 270.50 25810.25 95.42
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 347 2251.00 112550.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 36 166.25 11285.05 67.88
OCCT-97530HM-OT SESSION BY OT ASST 1 1.00 54.32 54.32
PHY-97110-PT SESSION BY LICENSED PT 22 154.25 10470.49 67.88
PHY-97110HM-PT SESSION BY PT ASST 1 1.50 81.48 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 18 138.25 9384.41 67.88
Subtotal (Total Children Is Unduplicated) 377 2712.25 143825.75 53.03
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Total 6300.25 292383.50 46.41
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Number of Children (Unduplicated) With at Least One Service 994
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Center 04
Flag Claims Units Chgs Paid
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R 8 12.75 471.75 0.00
U 0 0.00 0.00 0.00
B 2683 2546.50 97820.25 0.00
P 997 872.75 33419.25 33067.56
D 2 1.75 77.75 27.75
S 0 0.00 0.00 0.00
H 721 2359.00 119763.62 119488.42
T 0 0.00 0.00 0.00
258 507.50 40830.88 0.00
Other 0 0.00 0.00 0.00
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Total 4669 6300.25 292383.50 152583.73