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: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 373 1227.00 45399.00 37.00
Subtotal (Total Children Is Unduplicated) 373 1227.00 45399.00 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 5 6.00 450.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 3.00 225.00 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 15 18.50 1387.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 14 18.00 1350.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 9 13.50 749.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 10.00 750.00 75.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 6 6.00 436.68 72.78
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 4 4.00 200.60 50.15
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 3 3.00 150.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 4 4.00 194.00 48.50
Subtotal (Total Children Is Unduplicated) 60 104.50 6827.28 65.33
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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 30 95.75 6499.51 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 51 153.25 10402.61 67.88
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 10 24.00 1303.68 54.32
Subtotal (Total Children Is Unduplicated) 147 979.00 57464.72 58.70
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Total 2310.50 109691.00 47.48
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Number of Children (Unduplicated) With at Least One Service 379
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Center 05
Flag Claims Units Chgs Paid
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R 20 20.00 1364.20 0.00
U 0 0.00 0.00 0.00
B 2209 1161.75 43079.75 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
1276 1128.75 65247.05 0.00
Other 0 0.00 0.00 0.00
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Total 3505 2310.50 109691.00 0.00