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: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 653 3821.00 140306.00 36.72
Subtotal (Total Children Is Unduplicated) 653 3821.00 140306.00 36.72
----------------------------------------------------------------------------------------------------------------
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 131 193.50 14475.00 74.81
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 43 57.50 4286.00 74.54
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 208 306.00 16983.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 45 60.50 4537.50 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 56 59.00 2861.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 16 16.00 800.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 67 71.00 3428.94 48.29
Subtotal (Total Children Is Unduplicated) 389 875.00 53443.98 61.08
----------------------------------------------------------------------------------------------------------------
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
----------------------------------------------------------------------------------------------------------------
Total 10256.82 549483.23 53.57
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 659
----------------------------------------------------------------------------------------------------------------
Center 52
Flag Claims Units Chgs Paid
-------------------------------------------------
R 9 8.25 543.59 0.00
U 0 0.00 0.00 0.00
B 4730 2923.75 123109.62 60.16
P 3379 2072.50 89804.74 89777.14
D 0 0.00 0.00 0.00
S 9 25.25 934.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
2279 5227.07 335091.03 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 10406 10256.82 549483.23 89837.30