CMS/EIP Fiscal Report Center: 57
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 1099 7623.00 282016.00 37.00
Subtotal (Total Children Is Unduplicated) 1099 7623.00 282016.00 37.00
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Screening, Eval, and Assessment,Class #02
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 1 1.00 50.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 11 11.50 843.00 73.30
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 5.50 412.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 10 13.00 975.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 31 35.50 1970.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 217 225.50 16848.50 74.72
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 103 117.50 8786.00 74.77
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 404 431.00 23843.25 55.32
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 117 134.00 9850.00 73.51
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 25 27.00 1309.50 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 24 28.00 1358.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 19 19.00 921.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 2 2.00 100.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 45 50.00 2425.00 48.50
Subtotal (Total Children Is Unduplicated) 517 1106.50 69983.50 63.25
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EI Services,Class #03
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 3 6.00 417.10 69.52
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.00 25.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 480 8034.00 401100.00 49.93
OCCT-97530-OT SESSION BY LICENSED OT 48 277.00 18802.76 67.88
OCCT-97530HM-OT SESSION BY OT ASST 31 744.00 40414.08 54.32
PHY-97110-PT SESSION BY LICENSED PT 72 458.00 31085.04 67.87
PHY-97110HM-PT SESSION BY PT ASST 33 655.00 35579.56 54.32
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 4 7.00 350.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 56 281.75 19125.19 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 35 822.00 10850.40 13.20
Subtotal (Total Children Is Unduplicated) 556 11285.8 557749.13 49.42
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Total 20015.25 909748.63 45.45
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Number of Children (Unduplicated) With at Least One Service 1114
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Center 57
Flag Claims Units Chgs Paid
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R 287 338.50 12885.50 0.00
U 0 0.00 0.00 0.00
B 3583 3672.75 135869.75 64.75
P 3552 3563.00 131933.75 131881.97
D 11 11.50 425.50 0.00
S 26 65.50 3241.26 3185.76
H 0 0.00 0.00 0.00
T 69 212.50 10772.34 10772.34
4281 12151.00 614602.03 390680.17
Other 1 0.50 18.50 0.00
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Total 11810 20015.25 909748.63 536584.99