CMS/EIP Fiscal Report Center: 05
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Agency Filter:EIP DEI DEIP
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 593 4271.00 158027.00 37.00
Subtotal (Total Children Is Unduplicated) 593 4271.00 158027.00 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 9 9.00 675.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 9 9.00 675.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 10 11.50 787.50 68.48
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 4.00 222.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 5.00 375.00 75.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 19 19.00 1473.77 77.57
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 2 2.00 112.84 56.42
SCREEN-T1023-INTERDISCIPLINARY SCREENING 13 14.00 700.00 50.00
Subtotal (Total Children Is Unduplicated) 32 73.50 5021.11 68.31
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 4.50 225.00 50.00
PHY-97110-PT SESSION BY LICENSED PT 1 21.00 1425.48 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 3.00 203.64 67.88
Subtotal (Total Children Is Unduplicated) 2 28.50 1854.12 65.06
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Total 4373.00 164902.23 37.71
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Number of Children (Unduplicated) With at Least One Service 593
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Center 05
Flag Claims Units Chgs Paid
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R 50 51.75 3552.70 0.00
U 0 0.00 0.00 0.00
B 7950 4217.50 156662.38 50.00
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
189 103.75 4687.15 0.00
Other 0 0.00 0.00 0.00
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Total 8189 4373.00 164902.23 50.00