CMS/EIP Fiscal Report Center: 05
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 706 5077.50 187867.50 37.00
Subtotal (Total Children Is Unduplicated) 706 5077.50 187867.50 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 2.00 150.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 12 13.00 975.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 10 10.00 750.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.50 83.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 41 45.50 3412.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 9 9.00 675.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 42 48.00 3525.00 73.44
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 28 39.00 2164.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 13.00 975.00 75.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 37 37.00 2802.00 75.73
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 17 19.00 1003.01 52.79
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 20 22.00 1052.44 47.84
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 15 15.00 727.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 29 36.00 1746.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 8 8.00 388.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 36 42.00 2100.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 36 38.00 1843.00 48.50
Subtotal (Total Children Is Unduplicated) 218 398.00 24372.20 61.24
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 119 930.00 46500.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 79 700.50 47549.94 67.88
OCCT-97530HM-OT SESSION BY OT ASST 10 56.75 3082.66 54.32
PHY-97110-PT SESSION BY LICENSED PT 128 1113.75 75601.35 67.88
PHY-97110HM-PT SESSION BY PT ASST 1 1.50 81.48 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 142 1319.00 89533.72 67.88
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 14 54.50 2960.44 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 10 26.00 343.20 13.20
Subtotal (Total Children Is Unduplicated) 264 4202.00 265652.79 63.22
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Total 9677.50 477892.49 49.38
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Number of Children (Unduplicated) With at Least One Service 708
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Center 05
Flag Claims Units Chgs Paid
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R 70 71.75 4671.79 0.00
U 0 0.00 0.00 0.00
B 9352 5051.00 188068.90 250.00
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
6888 4554.75 285151.80 0.00
Other 0 0.00 0.00 0.00
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Total 16310 9677.50 477892.49 250.00