CMS/EIP Fiscal Report Center: 55
Services beginning 10/01/2008 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 150 71.00 2627.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 281 338.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 80 44.75 1655.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 689 1940.25 71585.75 36.90
TCON-TCON-TRANSITION CONFERENCE 37 37.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 692 2431.00 75868.50 31.21
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Screening, Eval, and Assessment,Class #02
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 6 9.00 1125.00 125.00
EVAL-EVAL-DEVELOPMENTAL EVALUATION 33 60.00 3248.50 54.14
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.50 262.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.50 112.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.00 225.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.00 111.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 111 199.41 14962.50 75.03
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 45 76.50 5737.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 21 33.00 2475.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 53 100.50 5607.00 55.79
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 61 91.50 6862.50 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 5 5.00 242.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 22 22.00 1067.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 4 4.00 194.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 9 9.00 436.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 34 34.00 1649.00 48.50
Subtotal (Total Children Is Unduplicated) 221 653.91 44318.00 67.77
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.00 440.89 220.45
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 2 0.50 25.00 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.00 50.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.00 25.00 25.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 3 38.75 1937.50 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 51 270.50 13525.00 50.00
INTR-INTR-INTERPRETER 1 10.00 464.00 46.40
OCCT-97530-OT SESSION BY LICENSED OT 123 623.75 42340.15 67.88
OCCT-97530HM-OT SESSION BY OT ASST 14 67.75 3680.18 54.32
PHY-97110-PT SESSION BY LICENSED PT 84 474.75 32226.03 67.88
PHY-97110HM-PT SESSION BY PT ASST 15 41.75 2267.86 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 258 2866.42 99176.62 34.60
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 259 55371.0 42738.34 0.77
Subtotal (Total Children Is Unduplicated) 348 59769.2 238896.57 4.00
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Total 62854.08 359083.07 5.71
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Number of Children (Unduplicated) With at Least One Service 762
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Center 55
Flag Claims Units Chgs Paid
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R 31 38.75 1433.75 0.00
U 0 0.00 0.00 0.00
B 14 19.50 1405.50 0.00
P 5871 59355.30 189195.72 189195.72
D 21 16.00 649.00 0.00
S 11 14.25 527.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
4026 3409.78 165853.35 0.00
Other 1 0.50 18.50 0.00
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Total 9975 62854.08 359083.07 189195.72