CMS/EIP Fiscal Report Center: 07
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Payclass Filters:OTHER
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 5.50 203.50 37.00
Subtotal (Total Children Is Unduplicated) 1 5.50 203.50 37.00
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 46 90.50 5022.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 17.50 1312.50 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 3.00 145.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 1.00 50.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 2 2.00 97.00 48.50
Subtotal (Total Children Is Unduplicated) 54 115.00 6676.25 58.05
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EI Services,Class #03
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 0.25 12.50 50.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 2 1.00 50.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 3 2.00 50.00 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 2 1.25 62.50 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 2 0.75 19.02 25.36
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 8 -9.00 -450.00 0.00
OCCT-97530-OT SESSION BY LICENSED OT 1 0.50 33.94 67.88
PHY-97110-PT SESSION BY LICENSED PT 1 4.50 305.46 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 12 31.75 2146.25 67.60
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 225.00 112.50 0.50
Subtotal (Total Children Is Unduplicated) 24 258.00 2342.17 9.08
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Total 378.50 9221.92 24.36
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Number of Children (Unduplicated) With at Least One Service 76
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Center 07
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 8 12.25 716.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
101 366.25 8505.67 0.00
Other 0 0.00 0.00 0.00
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Total 109 378.50 9221.92 0.00