CMS/EIP Fiscal Report Center: 55
Services beginning 10/01/2008 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 338 839.50 30996.75 36.92
Subtotal (Total Children Is Unduplicated) 338 839.50 30996.75 36.92
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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 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 2 3.00 225.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.00 111.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 15 29.00 2175.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 12 18.00 1350.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 9.00 675.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 19 34.00 1887.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 26 38.50 2887.50 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 3 3.00 145.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 6 6.00 291.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 3 3.00 145.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 3 3.00 145.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 8 8.00 388.00 48.50
Subtotal (Total Children Is Unduplicated) 76 162.00 10938.50 67.52
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 28 151.00 7550.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 47 247.75 16817.27 67.88
OCCT-97530HM-OT SESSION BY OT ASST 9 41.00 2227.12 54.32
PHY-97110-PT SESSION BY LICENSED PT 25 126.00 8552.88 67.88
PHY-97110HM-PT SESSION BY PT ASST 6 15.00 814.80 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 91 458.75 31139.95 67.88
Subtotal (Total Children Is Unduplicated) 132 1039.50 67102.02 64.55
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Total 2041.00 109037.27 53.42
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Number of Children (Unduplicated) With at Least One Service 372
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Center 55
Flag Claims Units Chgs Paid
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R 30 38.25 1415.25 0.00
U 0 0.00 0.00 0.00
B 11 15.00 1068.00 0.00
P 856 815.50 31115.75 31115.75
D 0 0.00 0.00 0.00
S 6 7.25 268.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
1461 1165.00 75170.02 0.00
Other 0 0.00 0.00 0.00
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Total 2364 2041.00 109037.27 31115.75