CMS/EIP Fiscal Report Center: 05
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/16/2009 Page: 1
Payclass Filters:MED
Eligibility Filter:DEI Only
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 70 584.00 21608.00 37.00
Subtotal (Total Children Is Unduplicated) 70 584.00 21608.00 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 4.00 300.00 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 4.00 300.00 75.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 18 18.00 1328.23 73.79
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 15 17.00 890.17 52.36
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.00 48.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 23 28.00 1400.00 50.00
Subtotal (Total Children Is Unduplicated) 33 74.00 4416.90 59.69
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 1 6.00 407.28 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 8.50 576.98 67.88
Subtotal (Total Children Is Unduplicated) 1 14.50 984.26 67.88
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Total 672.50 27009.16 40.16
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Number of Children (Unduplicated) With at Least One Service 70
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Center 05
Flag Claims Units Chgs Paid
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R 20 20.00 1119.09 0.00
U 0 0.00 0.00 0.00
B 1061 611.00 23174.02 200.00
P 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
56 41.50 2716.05 0.00
Other 0 0.00 0.00 0.00
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Total 1137 672.50 27009.16 200.00