CMS/EIP Fiscal Report Center: 07
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 772 2249.50 83120.50 36.95
Subtotal (Total Children Is Unduplicated) 772 2249.50 83120.50 36.95
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 4.00 300.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.00 111.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 7.50 562.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 56 110.50 6132.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 117 328.50 24637.50 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 4 4.00 194.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 3 3.00 145.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 29 29.00 1450.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 6 6.00 291.00 48.50
Subtotal (Total Children Is Unduplicated) 160 496.50 33947.75 68.37
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 215 1350.50 67525.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 14 51.25 3275.21 63.91
OCCT-97530HM-OT SESSION BY OT ASST 1 5.00 271.60 54.32
PHY-97110-PT SESSION BY LICENSED PT 11 22.25 1303.75 58.60
PHY-97110HM-PT SESSION BY PT ASST 4 6.00 325.92 54.32
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 2 2.50 125.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 18 79.75 5413.43 67.88
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 1.50 81.48 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 1 0.50 6.60 13.20
Subtotal (Total Children Is Unduplicated) 249 1519.25 78327.99 51.56
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Total 4265.25 195396.24 45.81
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Number of Children (Unduplicated) With at Least One Service 826
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Center 07
Flag Claims Units Chgs Paid
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R 1 0.50 18.50 0.00
U 0 0.00 0.00 0.00
B 2099 1529.75 61949.50 0.00
P 1227 935.25 40726.00 40710.75
D 2 1.00 37.00 0.00
S 158 123.25 5263.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
660 1675.50 87401.99 0.00
Other 0 0.00 0.00 0.00
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Total 4147 4265.25 195396.24 40710.75