CMS/EIP Fiscal Report Center: 55
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
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 535 335.25 12395.00 36.97
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 842 1470.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 604 579.50 21441.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1389 8597.75 317683.25 36.95
TCON-TCON-TRANSITION CONFERENCE 221 222.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1389 11204.5 351519.75 31.37
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 1.00 48.50 48.50
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 15 20.00 2500.00 125.00
EVAL-EVAL-DEVELOPMENTAL EVALUATION 210 329.00 16836.00 51.17
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 1 2.00 111.00 55.50
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 14 25.00 1875.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 9 15.15 1136.18 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 8.00 600.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 9 13.50 1012.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 12.00 666.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 440 797.11 59715.06 74.91
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 250 443.39 33214.90 74.91
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 77 122.50 9187.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 180 345.50 19204.50 55.58
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 213 319.50 24337.50 76.17
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 40 43.00 2085.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 87 92.65 4493.53 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 21 21.18 1018.50 48.09
PSTH-97001-EVAL BY LICENSED PT, INITIAL 59 61.00 2958.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 143 155.00 7517.50 48.50
Subtotal (Total Children Is Unduplicated) 822 2826.48 188518.17 66.70
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 10 17.00 9638.65 566.98
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 12 13.25 662.50 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 3 3.00 150.00 50.00
CONPP-CONPP-CONSULT, PT, PHONE 3 3.00 75.00 25.00
CONSP-CONSP-CONSULT, SLP, PHONE 2 1.25 31.25 25.00
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 14 79.25 3962.50 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 23 340.50 17025.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 84 1088.00 54400.00 50.00
INTR-INTR-INTERPRETER 3 16.00 724.00 45.25
OCCT-97530-OT SESSION BY LICENSED OT 283 3223.96 218728.62 67.84
OCCT-97530HM-OT SESSION BY OT ASST 28 155.00 8406.64 54.24
PHY-97110-PT SESSION BY LICENSED PT 163 2415.37 114593.70 47.44
PHY-97110HM-PT SESSION BY PT ASST 28 238.49 12954.53 54.32
SENS-V5264-EARMOLD 1 2.00 37.44 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 494 7475.05 409633.68 54.80
SPL-92508-GROUP SPL SESSION PER CHILD 4 2.89 86.59 29.96
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 459 243292 189509.94 0.78
Subtotal (Total Children Is Unduplicated) 644 258366 1040620.04 4.03
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Total 272396.99 1580657.96 5.80
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Number of Children (Unduplicated) With at Least One Service 1398
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Center 55
Flag Claims Units Chgs Paid
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R 39 47.50 1757.50 0.00
U 0 0.00 0.00 0.00
B 87 121.50 8276.00 0.00
P 26734 257681.62 880674.20 880538.48
D 158 162.25 7644.25 111.00
S 36 41.25 1640.25 0.00
H 10 15.00 1368.00 0.00
T 0 0.00 0.00 0.00
17463 14327.37 679279.26 0.00
Other 1 0.50 18.50 0.00
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Total 44528 272396.99 1580657.96 880649.48