CMS/EIP Fiscal Report Center: 57
Services beginning 10/01/2008 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 570 1917.25 70919.75 36.99
Subtotal (Total Children Is Unduplicated) 570 1917.25 70919.75 36.99
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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 4 4.00 280.50 70.13
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 2.00 150.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 10 10.00 555.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 79 79.00 5925.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 101 101.00 5605.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 29 29.00 2175.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 5 5.00 242.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 7 7.00 339.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 3 3.00 145.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 18 18.00 873.00 48.50
Subtotal (Total Children Is Unduplicated) 141 259.00 16341.50 63.09
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EI Services,Class #03
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 1 1.00 50.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 276 2299.50 114975.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 34 164.00 11132.32 67.88
PHY-97110-PT SESSION BY LICENSED PT 41 179.00 12146.52 67.86
PHY-97110HM-PT SESSION BY PT ASST 2 3.00 162.92 54.31
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 40 163.25 11081.41 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 1 4.00 52.80 13.20
Subtotal (Total Children Is Unduplicated) 324 2813.75 149600.97 53.17
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Total 4990.00 236862.22 47.47
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Number of Children (Unduplicated) With at Least One Service 629
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Center 57
Flag Claims Units Chgs Paid
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R 136 157.50 5827.50 0.00
U 0 0.00 0.00 0.00
B 1092 1078.25 39876.75 0.00
P 652 622.50 23032.50 23032.40
D 10 10.75 397.75 0.00
S 9 21.50 1055.50 1000.00
H 0 0.00 0.00 0.00
T 13 41.50 2136.58 2136.58
1241 3057.50 164517.14 116429.27
Other 1 0.50 18.50 0.00
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Total 3154 4990.00 236862.22 142598.25