CMS/EIP Fiscal Report Center: 09
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 703 2045.50 75674.25 37.00
Subtotal (Total Children Is Unduplicated) 703 2045.50 75674.25 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 30 41.00 3075.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 6.00 450.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 16 16.50 1237.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 15 24.00 1800.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 16 25.50 1415.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 138 153.50 11512.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 37 71.50 5362.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 81 94.00 7050.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 113 178.00 9879.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 17 19.00 1425.00 75.00
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.00 48.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 12 15.00 750.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 270 646.00 44053.75 68.19
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.00 25.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 145 889.00 44450.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 86 467.75 31750.87 67.88
OCCT-97530HM-OT SESSION BY OT ASST 2 4.75 258.02 54.32
PHY-97110-PT SESSION BY LICENSED PT 106 695.75 47227.51 67.88
PHY-97110HM-PT SESSION BY PT ASST 6 50.50 2743.16 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 105 546.25 37079.45 67.88
Subtotal (Total Children Is Unduplicated) 325 2655.00 163534.01 61.59
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Total 5346.50 283262.01 52.98
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Number of Children (Unduplicated) With at Least One Service 831
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Center 09
Flag Claims Units Chgs Paid
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R 7 8.50 427.50 0.00
U 0 0.00 0.00 0.00
B 582 588.25 31642.34 27.75
P 2830 2577.00 116160.41 116060.41
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 1 0.75 27.75 27.75
T 0 0.00 0.00 0.00
784 2172.00 135004.01 0.00
Other 0 0.00 0.00 0.00
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Total 4204 5346.50 283262.01 116115.91