CMS/EIP Fiscal Report Center: 55
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
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 153 72.25 2673.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 248 316.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 114 88.75 3283.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 656 1906.00 70448.00 36.96
TCON-TCON-TRANSITION CONFERENCE 56 56.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 659 2439.00 76405.00 31.33
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Screening, Eval, and Assessment,Class #02
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 2 3.00 375.00 125.00
EVAL-EVAL-DEVELOPMENTAL EVALUATION 63 95.00 4750.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 9.00 675.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.00 150.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 3.00 225.00 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 2 4.00 222.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 94 168.00 12525.00 74.55
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 54 97.00 7275.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 19 30.00 2250.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 35 66.50 3690.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 38 57.00 4275.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 10 10.00 485.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 17 18.00 873.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 4 4.00 194.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 18 18.00 873.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 26 26.00 1261.00 48.50
Subtotal (Total Children Is Unduplicated) 229 613.50 40323.75 65.73
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.50 75.00 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 11 88.00 4400.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 42 295.25 14762.50 50.00
INTR-INTR-INTERPRETER 1 2.00 84.00 42.00
OCCT-97530-OT SESSION BY LICENSED OT 139 673.60 45642.60 67.76
OCCT-97530HM-OT SESSION BY OT ASST 9 39.25 2119.10 53.99
PHY-97110-PT SESSION BY LICENSED PT 84 359.06 24320.07 67.73
PHY-97110HM-PT SESSION BY PT ASST 15 34.94 1898.46 54.33
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 228 1331.72 88244.83 66.26
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.00 13.20 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 238 49088.0 37972.10 0.77
Subtotal (Total Children Is Unduplicated) 334 51914.3 219531.86 4.23
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Total 54966.82 336260.61 6.12
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Number of Children (Unduplicated) With at Least One Service 760
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Center 55
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 139 167.25 6701.25 0.00
P 5343 51638.03 176825.70 176825.70
D 11 10.75 474.25 55.50
S 11 12.75 471.75 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
3837 3138.04 151787.66 0.00
Other 0 0.00 0.00 0.00
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Total 9341 54966.82 336260.61 176881.20