CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/17/2009 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 572 243.25 9000.25 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 572 602.75 22292.50 36.98
TCM-T1017TL-TARGETED CASE MANAGEMENT 1076 2628.00 97236.00 37.00
Subtotal (Total Children Is Unduplicated) 1530 3474.00 128528.75 37.00
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 3 3.00 122.00 40.67
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 1.50 75.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 36 64.50 3225.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 11.50 862.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.50 112.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.00 150.00 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 4 7.00 388.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 105 148.00 10851.50 73.32
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 11 15.00 1125.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 36 54.50 4087.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 111 165.00 9154.50 55.48
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 35 52.50 3921.60 74.70
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 3.00 145.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.00 28.17 28.17
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 4 4.00 194.00 48.50
Subtotal (Total Children Is Unduplicated) 253 538.00 34716.77 64.53
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 9 35.00 9226.45 263.61
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 24 27.50 1355.00 49.27
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 11 3.25 81.25 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 2 3.00 150.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 6 4.00 100.00 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.00 50.00 50.00
CONPP-CONPP-CONSULT, PT, PHONE 1 0.25 6.25 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 2 3.00 150.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.00 25.00 25.00
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 5 9.00 270.00 30.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 27 191.00 4710.00 24.66
EIIF-90812-INDIVIDUAL PSYCHOTHERAPY, 45-50 MINUTES 1 5.00 271.55 54.31
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 9 75.00 3750.00 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 5 8.00 400.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 159 930.00 44523.00 47.87
INTR-INTR-INTERPRETER 28 484.00 4838.00 10.00
OCCT-97530-OT SESSION BY LICENSED OT 53 269.75 17955.66 66.56
PHY-97110-PT SESSION BY LICENSED PT 83 400.50 26687.04 66.63
PHY-97110HM-PT SESSION BY PT ASST 2 2.00 108.64 54.32
RSPT-RSPT-RESPITE 1 65.00 520.00 8.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 441 2414.12 160510.62 66.49
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 3.00 162.96 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 28 93.00 1280.74 13.77
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 886 195722 108128.14 0.55
Subtotal (Total Children Is Unduplicated) 997 200749 385260.30 1.92
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Total 204761.37 548505.82 2.68
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Number of Children (Unduplicated) With at Least One Service 1864
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Center 01
Flag Claims Units Chgs Paid
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R 1 0.25 9.25 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 5092 128618.12 253273.52 253273.52
D 25 35.00 2417.75 0.00
S 110 84.25 3117.25 0.00
H 16 20.50 1274.50 0.00
T 3314 68852.25 147858.24 147830.49
5825 7066.00 135540.65 0.00
Other 87 85.00 5014.66 0.00
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Total 14470 204761.37 548505.82 401104.01