CMS/EIP Fiscal Report Center: 52
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Payclass Filters:GR
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 441 238.50 8824.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 351 443.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 308 232.50 8602.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 436 1157.25 42291.00 36.54
TCON-TCON-TRANSITION CONFERENCE 56 57.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 728 2128.25 59718.00 28.06
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-TRANSITION ASSESSMENT 10 12.50 625.00 50.00
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 38 38.00 1900.00 50.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 11 14.00 816.00 58.29
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 6.89 336.00 48.77
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 6 9.50 527.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.00 225.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.00 48.50 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 2 2.00 82.44 41.22
PSTH-97001-EVAL BY LICENSED PT, INITIAL 4 4.00 194.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 4 4.00 194.00 48.50
Subtotal (Total Children Is Unduplicated) 77 100.89 5239.19 51.93
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 32 33.25 1662.50 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 1 0.50 12.50 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 16 11.25 562.50 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 1 0.25 6.25 25.00
CONOP-CONOP-CONSULT, OT, PHONE 1 0.25 6.25 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 0.25 12.50 50.00
CONPP-CONPP-CONSULT, PT, PHONE 3 1.25 31.25 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 7 5.00 250.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 49 274.80 13740.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 17 72.91 4948.89 67.88
PHY-97110-PT SESSION BY LICENSED PT 35 131.36 8914.91 67.87
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 82 502.47 34107.28 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 498 91580.5 45790.27 0.50
Subtotal (Total Children Is Unduplicated) 519 92614.1 110045.10 1.19
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Total 94843.22 175002.29 1.85
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Number of Children (Unduplicated) With at Least One Service 772
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Center 52
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 1 26.00 13.00 0.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 1016 41501.96 56509.88 56403.38
4986 53315.26 118479.41 0.00
Other 0 0.00 0.00 0.00
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Total 6003 94843.22 175002.29 56403.38