CMS/EIP Fiscal Report Center: 55
Services beginning 01/01/2008 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 1 1.00 0.00 0.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 5 8.00 296.00 37.00
Subtotal (Total Children Is Unduplicated) 5 9.00 296.00 32.89
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 34 54.50 2925.00 53.67
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 3 4.22 316.87 75.09
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 2.91 218.74 75.17
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 0.06 4.98 83.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.00 225.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 99 154.91 11624.57 75.04
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 65 93.37 7004.92 75.02
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 13.37 1002.28 74.96
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 14 27.50 1555.50 56.56
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 51 76.50 6150.00 80.39
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 13 11.08 540.18 48.75
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 25 25.60 1241.70 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 4 3.25 148.94 45.83
PSTH-97001-EVAL BY LICENSED PT, INITIAL 15 14.28 692.62 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 28 26.18 1270.10 48.51
Subtotal (Total Children Is Unduplicated) 216 512.73 35032.40 68.33
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.00 50.00 50.00
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 1.00 50.00 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 7.00 350.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 10.00 500.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 104 679.68 46122.39 67.86
OCCT-97530HM-OT SESSION BY OT ASST 6 12.47 678.26 54.39
PHY-97110-PT SESSION BY LICENSED PT 60 402.28 27283.82 67.82
PHY-97110HM-PT SESSION BY PT ASST 9 36.54 1988.50 54.42
SENS-V5264-EARMOLD 1 2.00 37.44 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 133 830.03 56307.02 67.84
SPL-92508-GROUP SPL SESSION PER CHILD 2 0.89 60.19 67.63
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 2 51.00 45.70 0.90
Subtotal (Total Children Is Unduplicated) 207 2033.89 133473.32 65.62
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Total 2555.62 168801.72 66.05
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Number of Children (Unduplicated) With at Least One Service 320
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Center 55
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 13 12.50 820.02 684.80
D 4 5.50 350.00 0.00
S 0 0.00 0.00 0.00
H 10 15.00 1368.00 0.00
T 0 0.00 0.00 0.00
3752 2522.62 166263.70 0.00
Other 0 0.00 0.00 0.00
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Total 3779 2555.62 168801.72 684.80