CMS/EIP Fiscal Report Center: 01
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 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 9 4.50 166.50 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 30 45.25 1674.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 87 261.25 9666.25 37.00
Subtotal (Total Children Is Unduplicated) 102 311.00 11507.00 37.00
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 6 10.00 500.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 7.50 562.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 11 17.50 1312.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 8 12.00 666.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 44 64.00 4913.29 76.77
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 45 65.00 3607.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 68 98.50 7387.50 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 2 3.00 120.44 40.15
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 12 14.00 1441.79 102.99
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 7 7.00 327.20 46.74
PSTH-97001-EVAL BY LICENSED PT, INITIAL 7 6.00 788.50 131.42
SPCH-92506-SPEECH EVAL BY LICENSED SLP 17 36.00 2660.34 73.90
Subtotal (Total Children Is Unduplicated) 171 341.50 24362.56 71.34
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 11 33.75 11804.38 349.76
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 3 3.50 175.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 4 5.50 275.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.50 75.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 6 22.00 1100.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 81 506.25 62965.71 124.38
OCCT-97530HM-OT SESSION BY OT ASST 3 3.75 354.54 94.54
PHY-97110-PT SESSION BY LICENSED PT 82 381.75 34492.03 90.35
PHY-97110HM-PT SESSION BY PT ASST 2 1.50 119.04 79.36
SENS-V5264-EARMOLD 1 1.00 18.72 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 171 815.05 71086.98 87.22
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.00 100.00 100.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 8 361.00 185.70 0.51
Subtotal (Total Children Is Unduplicated) 252 2137.55 182752.10 85.50
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Total 2790.05 218621.66 78.36
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Number of Children (Unduplicated) With at Least One Service 448
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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 295 466.00 36113.11 36786.92
D 17 27.50 1838.25 0.00
S 99 114.50 4236.50 0.00
H 71 96.50 6098.88 0.00
T 56 79.00 5206.71 5206.71
1240 1739.80 153152.26 0.00
Other 173 266.75 11975.95 0.00
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Total 1951 2790.05 218621.66 41993.63