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: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 1072 3732.00 138084.00 37.00
Subtotal (Total Children Is Unduplicated) 1072 3732.00 138084.00 37.00
----------------------------------------------------------------------------------------------------------------
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 19 18.50 1026.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 37 22.00 1650.00 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 28 20.50 1537.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 99 96.50 5355.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 24 23.50 1762.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 72 72.00 13320.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 3 3.00 825.00 275.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 38 38.00 3990.00 105.00
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) 208 335.00 31912.00 95.26
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 348 2259.00 112950.00 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) 378 2720.25 144225.75 53.02
----------------------------------------------------------------------------------------------------------------
Total 6787.25 314221.75 46.30
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1122
----------------------------------------------------------------------------------------------------------------
Center 04
Flag Claims Units Chgs Paid
-------------------------------------------------
R 12 22.50 832.50 0.00
U 0 0.00 0.00 0.00
B 2983 2887.25 111722.75 0.00
P 1105 981.25 37566.25 37214.56
D 2 1.75 77.75 27.75
S 0 0.00 0.00 0.00
H 723 2367.00 120163.62 119888.42
T 0 0.00 0.00 0.00
277 527.50 43858.88 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 5102 6787.25 314221.75 157130.73