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: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
TCM-T1017TL-TARGETED CASE MANAGEMENT 1 2.00 74.00 37.00
Subtotal (Total Children Is Unduplicated) 1 2.00 74.00 37.00
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 2 3.50 175.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 6.00 450.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 7.50 416.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 19 29.50 2212.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 16 23.50 1304.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 15 22.50 1687.50 75.00
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 47.73 47.73
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.00 97.64 97.64
Subtotal (Total Children Is Unduplicated) 44 94.50 6390.87 67.63
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 0.00 2271.35 0.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 1.50 75.00 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 12.00 600.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 9 25.00 3026.17 121.05
PHY-97110-PT SESSION BY LICENSED PT 13 26.00 2410.74 92.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 44 79.80 7012.65 87.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 4 145.00 77.70 0.54
Subtotal (Total Children Is Unduplicated) 67 290.80 15548.61 53.47
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Total 387.30 22013.48 56.84
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Number of Children (Unduplicated) With at Least One Service 109
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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 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 29 42.00 2760.38 0.00
T 5 8.00 543.04 543.04
184 273.30 14513.93 0.00
Other 54 64.00 4196.13 0.00
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Total 272 387.30 22013.48 543.04