CMS/EIP Fiscal Report Center: 01
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Payclass Filters:TPIN
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
CASE-CASE-NON-TCM CASE MANAGEMENT 8 4.25 157.25 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 17 18.75 693.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 80 181.50 6715.50 37.00
Subtotal (Total Children Is Unduplicated) 80 204.50 7566.50 37.00
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 3.00 150.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.50 112.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 7.50 562.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.00 166.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 29 39.50 3074.09 77.83
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 40 56.50 3135.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 29 39.50 2962.50 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 63.42 63.42
SPCH-92506-SPEECH EVAL BY LICENSED SLP 2 2.00 433.99 217.00
Subtotal (Total Children Is Unduplicated) 72 154.50 10736.25 69.49
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 2.00 69.82 34.91
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 2 2.00 100.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 1.00 50.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 16 52.00 2600.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 23 60.00 8261.12 137.69
OCCT-97530HM-OT SESSION BY OT ASST 1 1.00 120.00 120.00
PHY-97110-PT SESSION BY LICENSED PT 28 48.75 4716.75 96.75
PHY-97110HM-PT SESSION BY PT ASST 1 0.75 67.68 90.24
SENS-V5264-EARMOLD 1 1.00 18.72 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 60 118.50 9704.18 81.89
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.00 100.00 100.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 5 216.00 108.00 0.50
Subtotal (Total Children Is Unduplicated) 117 504.00 25916.27 51.42
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Total 863.00 44219.02 51.24
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Number of Children (Unduplicated) With at Least One Service 238
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Center 01
Flag Claims Units Chgs Paid
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R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 4 12.25 2087.73 1929.48
D 0 0.00 0.00 0.00
S 7 7.50 277.50 0.00
H 31 37.50 2481.50 0.00
T 49 68.00 4513.67 4513.67
490 505.50 25255.77 0.00
Other 124 232.25 9602.85 0.00
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Total 705 863.00 44219.02 6443.15