CMS/EIP Fiscal Report Center: 52
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 394 210.50 7779.25 36.96
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 388 480.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 347 309.25 11433.00 36.97
TCM-T1017TL-TARGETED CASE MANAGEMENT 394 1106.50 40404.00 36.52
TCON-TCON-TRANSITION CONFERENCE 61 62.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 678 2168.25 59616.25 27.50
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-TRANSITION ASSESSMENT 5 5.50 275.00 50.00
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 3 3.00 150.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.00 150.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.00 161.00 53.67
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 58 59.50 2973.50 49.97
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 21 29.16 2133.82 73.18
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.00 48.50 48.50
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 15 16.99 857.00 50.44
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 24 37.65 2089.25 55.49
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 8.00 600.00 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 4 4.00 194.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.00 97.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 4 4.00 194.00 48.50
Subtotal (Total Children Is Unduplicated) 115 178.80 10068.57 56.31
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EI Services,Class #03
AUD-HA_FUP-AUDIOLOGY SERVICES 1 0.10 5.16 51.60
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 35 41.00 2050.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 17 11.75 587.50 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 1 0.25 6.25 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 3 1.50 75.00 50.00
CONPP-CONPP-CONSULT, PT, PHONE 3 1.25 31.25 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 8 6.50 325.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 2 1.25 31.25 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 52 245.46 12273.06 50.00
INTR-INTR-INTERPRETER 1 2.00 100.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 18 121.64 8256.70 67.88
PHY-97110-PT SESSION BY LICENSED PT 37 151.50 10283.15 67.88
SENS-V5264-EARMOLD 1 2.00 37.44 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 83 486.42 33000.06 67.84
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 530 103856 51919.00 0.50
Subtotal (Total Children Is Unduplicated) 548 104929 118980.82 1.13
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Total 107275.67 188665.64 1.76
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Number of Children (Unduplicated) With at Least One Service 738
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Center 52
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 1 0.25 9.25 0.00
P 2 0.50 18.50 18.50
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
6077 107274.92 188637.89 0.00
Other 0 0.00 0.00 0.00
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Total 6080 107275.67 188665.64 18.50