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: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 4 6.50 240.50 37.00
Subtotal (Total Children Is Unduplicated) 4 7.50 240.50 32.07
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 8 15.50 925.00 59.68
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 40 66.33 4981.47 75.10
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 16 26.50 1987.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 4.25 318.56 74.96
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 10 19.50 1111.50 57.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 16 24.00 1800.00 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 11 10.44 506.40 48.51
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 0.66 32.00 48.48
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 3 2.66 129.00 48.50
Subtotal (Total Children Is Unduplicated) 66 171.84 11888.43 69.18
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 40 164.71 11182.89 67.89
OCCT-97530HM-OT SESSION BY OT ASST 3 8.50 461.72 54.32
PHY-97110-PT SESSION BY LICENSED PT 26 84.42 5729.80 67.87
PHY-97110HM-PT SESSION BY PT ASST 4 7.00 380.24 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 57 211.81 14383.07 67.91
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 2 51.00 45.70 0.90
Subtotal (Total Children Is Unduplicated) 101 527.44 32183.42 61.02
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Total 706.78 44312.35 62.70
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Number of Children (Unduplicated) With at Least One Service 150
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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 8 5.00 320.02 320.02
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
852 701.78 43992.33 0.00
Other 0 0.00 0.00 0.00
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Total 860 706.78 44312.35 320.02