CMS/EIP Fiscal Report Center: 51
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 505 2171.50 80277.50 36.97
Subtotal (Total Children Is Unduplicated) 505 2171.50 80277.50 36.97
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 4.00 300.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 5.00 375.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 48 55.50 4162.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 13 16.00 1200.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 3.50 262.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 6 7.50 416.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 72 85.00 6301.50 74.14
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 1 1.00 40.50 40.50
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 7 7.00 339.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 2.00 97.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 13 13.00 630.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 8 8.00 388.00 48.50
Subtotal (Total Children Is Unduplicated) 106 208.50 14561.75 69.84
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EI Services,Class #03
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 2 12.00 881.04 73.42
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 130 847.50 42375.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 55 321.25 21806.45 67.88
OCCT-97530HM-OT SESSION BY OT ASST 11 32.75 1778.98 54.32
PHY-97110-PT SESSION BY LICENSED PT 66 352.00 23741.21 67.45
PHY-97110HM-PT SESSION BY PT ASST 19 110.00 5975.20 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 70 440.00 29480.62 67.00
SPL-92508-GROUP SPL SESSION PER CHILD 2 2.75 36.30 13.20
Subtotal (Total Children Is Unduplicated) 209 2118.25 126074.80 59.52
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Total 4498.25 220914.05 49.11
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Number of Children (Unduplicated) With at Least One Service 519
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Center 51
Flag Claims Units Chgs Paid
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R 2 2.00 150.00 0.00
U 0 0.00 0.00 0.00
B 3196 2251.00 84946.30 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
917 2245.25 135817.75 0.00
Other 0 0.00 0.00 0.00
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Total 4115 4498.25 220914.05 0.00