CMS/EIP Fiscal Report Center: 52
Services beginning 10/01/2008 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 321 974.75 35890.00 36.82
Subtotal (Total Children Is Unduplicated) 321 974.75 35890.00 36.82
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 2.50 187.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 2.50 138.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 28 41.50 3112.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 4.50 337.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 8.50 637.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 63 91.50 5078.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 13.50 1012.50 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 2 2.00 97.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 1.00 50.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 3 3.00 145.50 48.50
Subtotal (Total Children Is Unduplicated) 86 171.50 10845.50 63.24
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 29 106.00 5300.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 4 30.75 2087.31 67.88
PHY-97110-PT SESSION BY LICENSED PT 2 2.00 135.76 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 15 67.50 4581.90 67.88
Subtotal (Total Children Is Unduplicated) 46 206.25 12104.97 58.69
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Total 1352.50 58840.47 43.50
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Number of Children (Unduplicated) With at Least One Service 325
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Center 52
Flag Claims Units Chgs Paid
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R 8 8.00 534.34 0.00
U 0 0.00 0.00 0.00
B 1257 784.50 32881.67 9.25
P 756 481.00 21115.21 21115.21
D 0 0.00 0.00 0.00
S 3 9.50 351.50 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
68 69.50 3957.75 0.00
Other 0 0.00 0.00 0.00
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Total 2092 1352.50 58840.47 21124.46