CMS/EIP Fiscal Report Center: 09
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
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 4 4.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 0.50 18.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 6 8.50 314.50 37.00
Subtotal (Total Children Is Unduplicated) 11 13.00 333.00 25.62
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 35 51.00 3825.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 5.00 375.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 16 17.50 1312.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 23 39.50 2962.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 7 8.00 444.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 143 152.50 11437.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 25 31.50 2362.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 87 90.00 6750.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 41 45.00 2497.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 37 37.00 2775.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 2 2.00 97.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 3 5.00 242.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.00 97.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 3 3.00 150.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 5 6.00 291.00 48.50
Subtotal (Total Children Is Unduplicated) 203 496.00 35667.50 71.91
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.50 75.00 50.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 2.00 100.00 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.00 50.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 17.00 850.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 126 634.75 43120.77 67.93
OCCT-97530HM-OT SESSION BY OT ASST 6 18.00 977.76 54.32
PHY-97110-PT SESSION BY LICENSED PT 106 498.50 33820.30 67.84
PHY-97110HM-PT SESSION BY PT ASST 3 30.00 1629.60 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 163 720.00 48873.60 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 1 6.50 85.80 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 5 140.00 70.00 0.50
Subtotal (Total Children Is Unduplicated) 289 2069.25 129652.83 62.66
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Total 2578.25 165653.33 64.25
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Number of Children (Unduplicated) With at Least One Service 450
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Center 09
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 2 3.50 244.70 355.37
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
1569 2574.75 165408.63 0.00
Other 0 0.00 0.00 0.00
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Total 1571 2578.25 165653.33 355.37