CMS/EIP Fiscal Report Center: 52
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
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 564 3414.25 125404.25 36.73
Subtotal (Total Children Is Unduplicated) 564 3414.25 125404.25 36.73
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Screening, Eval, and Assessment,Class #02
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.00 21.79 21.79
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 2 2.00 225.00 112.50
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 8.00 600.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 4.00 300.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.50 112.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 8.50 471.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 105 156.00 11662.50 74.76
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 5.50 412.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 26 37.50 2786.00 74.29
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 161 242.00 13431.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 41 55.00 4125.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 6 6.00 291.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 58 64.00 3104.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 8 11.00 533.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 43 46.00 2231.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 7 7.00 350.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 64 68.00 3283.44 48.29
Subtotal (Total Children Is Unduplicated) 319 723.00 43940.98 60.78
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 110 1151.25 57562.50 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 1 32.00 1600.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 96 1213.75 82199.51 67.72
PHY-97110-PT SESSION BY LICENSED PT 99 1290.60 87604.57 67.88
PHY-97110HM-PT SESSION BY PT ASST 3 24.25 1317.26 54.32
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 2.50 125.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 184 1846.47 125324.41 67.87
Subtotal (Total Children Is Unduplicated) 318 5560.82 355733.25 63.97
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Total 9698.07 525078.48 54.14
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Number of Children (Unduplicated) With at Least One Service 570
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Center 52
Flag Claims Units Chgs Paid
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R 9 8.25 543.59 0.00
U 0 0.00 0.00 0.00
B 4349 2645.50 111471.62 60.16
P 3061 1835.25 79482.74 79461.24
D 0 0.00 0.00 0.00
S 8 22.00 814.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
2244 5187.07 332766.53 0.00
Other 0 0.00 0.00 0.00
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Total 9671 9698.07 525078.48 79521.40