CMS/EIP Fiscal Report Center: 05
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 305 1037.50 38387.50 37.00
Subtotal (Total Children Is Unduplicated) 305 1037.50 38387.50 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.00 75.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 5.00 375.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 2.00 150.00 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 14 17.50 1312.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 10 14.00 1050.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 8 12.00 666.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 6.00 450.00 75.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 4 4.00 291.12 72.78
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 3 3.00 145.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 3.00 145.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 8 8.00 388.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.00 97.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 1.00 50.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 4 4.00 194.00 48.50
Subtotal (Total Children Is Unduplicated) 52 84.00 5472.87 65.15
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 81 477.00 23850.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 29 94.75 6431.63 67.88
OCCT-97530HM-OT SESSION BY OT ASST 4 10.00 543.20 54.32
PHY-97110-PT SESSION BY LICENSED PT 68 219.00 14865.72 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 50 151.75 10300.79 67.88
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 10 24.00 1303.68 54.32
Subtotal (Total Children Is Unduplicated) 146 976.50 57295.02 58.67
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Total 2098.00 101155.39 48.22
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Number of Children (Unduplicated) With at Least One Service 311
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Center 05
Flag Claims Units Chgs Paid
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R 13 13.00 941.12 0.00
U 0 0.00 0.00 0.00
B 1864 972.25 36068.25 0.00
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
1258 1112.75 64146.02 0.00
Other 0 0.00 0.00 0.00
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Total 3135 2098.00 101155.39 0.00