CMS/EIP Fiscal Report Center: 55
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 150 71.00 2627.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 280 337.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 80 44.75 1655.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 319 950.25 35020.50 36.85
TCON-TCON-TRANSITION CONFERENCE 37 37.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 497 1440.00 39303.25 27.29
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Screening, Eval, and Assessment,Class #02
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 5 7.00 875.00 125.00
EVAL-EVAL-DEVELOPMENTAL EVALUATION 28 44.50 2323.50 52.21
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.50 112.50 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 54 82.58 6193.53 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 14 21.00 1575.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 12.25 918.94 75.02
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 17 33.50 1859.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 15.00 1125.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.00 48.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 6 5.56 269.60 48.49
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 0.34 16.50 48.53
PSTH-97001-EVAL BY LICENSED PT, INITIAL 5 5.00 242.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 24 23.34 1132.00 48.50
Subtotal (Total Children Is Unduplicated) 137 252.57 16691.82 66.09
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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 24 119.50 5975.00 50.00
INTR-INTR-INTERPRETER 1 10.00 464.00 46.40
OCCT-97530-OT SESSION BY LICENSED OT 51 211.29 14339.99 67.87
OCCT-97530HM-OT SESSION BY OT ASST 3 18.25 991.34 54.32
PHY-97110-PT SESSION BY LICENSED PT 49 264.33 17943.35 67.88
PHY-97110HM-PT SESSION BY PT ASST 8 19.75 1072.82 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 148 2195.86 53653.60 24.43
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 259 55320.0 42692.64 0.77
Subtotal (Total Children Is Unduplicated) 311 58202.2 139611.13 2.40
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Total 59894.80 195606.20 3.27
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Number of Children (Unduplicated) With at Least One Service 597
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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 4887 58389.30 152015.45 152015.45
D 21 16.00 649.00 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
1684 1489.50 42941.75 0.00
Other 0 0.00 0.00 0.00
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Total 6592 59894.80 195606.20 152015.45