CMS/EIP Fiscal Report Center: 52
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Agency Filter:EIP DEI DEIP
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
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 7.00 525.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 3.00 225.00 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 22 32.50 2437.50 75.00
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 34 45.50 3412.50 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.00 48.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 4 4.00 194.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 7 7.00 350.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 9 9.00 436.50 48.50
Subtotal (Total Children Is Unduplicated) 219 523.50 33767.75 64.50
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 50 367.25 18362.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 4 60.75 4123.71 67.88
PHY-97110-PT SESSION BY LICENSED PT 2 2.00 135.76 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 31 214.75 14577.23 67.88
Subtotal (Total Children Is Unduplicated) 82 644.75 37199.20 57.70
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Total 4582.50 196371.20 42.85
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Number of Children (Unduplicated) With at Least One Service 567
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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 4348 2644.50 111423.12 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
71 72.50 4107.75 0.00
Other 0 0.00 0.00 0.00
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Total 7497 4582.50 196371.20 79521.40