CMS/EIP Fiscal Report Center: 51
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 938 7923.25 293018.25 36.98
Subtotal (Total Children Is Unduplicated) 938 7923.25 293018.25 36.98
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Screening, Eval, and Assessment,Class #02
AUD-92626-EVAL OF AUD REHAB STATUS 1 1.00 36.07 36.07
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.00 10.80 10.80
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 12 13.00 948.50 72.96
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 6 6.00 450.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 2.50 187.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 35 37.00 2775.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.00 55.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 109 119.50 8962.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 39 46.50 3487.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 13 16.00 1200.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 20 27.50 1526.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 278 310.00 22995.50 74.18
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 3 3.00 121.50 40.50
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 3 3.00 236.53 78.84
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 23 27.00 1309.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 17 19.00 874.00 46.00
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 15 18.00 873.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 44 44.00 2134.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 45 50.00 2425.00 48.50
Subtotal (Total Children Is Unduplicated) 409 745.00 50608.65 67.93
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 3 4.00 508.02 127.01
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 3 32.00 2349.44 73.42
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 4 12.00 300.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 257 3488.75 174091.50 49.90
OCCT-97530-OT SESSION BY LICENSED OT 94 1208.75 81837.73 67.70
OCCT-97530HM-OT SESSION BY OT ASST 29 239.25 12996.06 54.32
PHY-97110-PT SESSION BY LICENSED PT 123 1319.75 89364.24 67.71
PHY-97110HM-PT SESSION BY PT ASST 37 309.00 16704.90 54.06
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 131 1362.75 91925.51 67.46
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 3 12.25 665.42 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 16 33.25 438.90 13.20
Subtotal (Total Children Is Unduplicated) 373 8021.75 471181.72 58.74
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Total 16690.00 814808.62 48.82
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Number of Children (Unduplicated) With at Least One Service 942
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Center 51
Flag Claims Units Chgs Paid
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R 3 3.00 187.00 0.00
U 0 0.00 0.00 0.00
B 12303 8327.25 317176.36 0.00
P 1 1.00 67.88 0.00
D 1 1.00 75.00 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
3438 8357.75 497302.38 0.00
Other 0 0.00 0.00 0.00
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Total 15746 16690.00 814808.62 0.00