CMS/EIP Fiscal Report Center: 55
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 763 4237.25 156650.75 36.97
Subtotal (Total Children Is Unduplicated) 763 4237.25 156650.75 36.97
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Screening, Eval, and Assessment,Class #02
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 1 2.00 250.00 125.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 9.50 712.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.00 150.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.50 112.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 6 9.00 675.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 10.00 555.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 123 238.00 17775.00 74.68
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 80 146.00 10950.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 24 37.50 2812.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 90 168.50 9351.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 117 174.00 13012.50 74.78
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 9 9.00 436.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 20 20.00 970.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 5 5.00 242.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 17 17.00 824.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 28 29.00 1406.50 48.50
Subtotal (Total Children Is Unduplicated) 319 878.00 60236.75 68.61
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 41 432.50 21625.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 123 1226.75 83186.94 67.81
OCCT-97530HM-OT SESSION BY OT ASST 12 88.75 4820.90 54.32
PHY-97110-PT SESSION BY LICENSED PT 69 445.50 30240.54 67.88
PHY-97110HM-PT SESSION BY PT ASST 17 108.50 5893.72 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 183 1574.75 106877.06 67.87
SPL-92508-GROUP SPL SESSION PER CHILD 2 2.00 26.40 13.20
Subtotal (Total Children Is Unduplicated) 261 3878.75 252670.56 65.14
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Total 8994.00 469558.06 52.21
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Number of Children (Unduplicated) With at Least One Service 782
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Center 55
Flag Claims Units Chgs Paid
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R 39 47.50 1757.50 0.00
U 0 0.00 0.00 0.00
B 87 121.50 8276.00 0.00
P 4178 4220.00 159337.25 159336.75
D 0 0.00 0.00 0.00
S 36 41.25 1640.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
5759 4563.25 298528.56 0.00
Other 1 0.50 18.50 0.00
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Total 10100 8994.00 469558.06 159336.75