CMS/EIP Fiscal Report Center: 04
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 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 930 563.75 20858.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 424 424.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 50 31.75 1138.75 35.87
TCM-T1017TL-TARGETED CASE MANAGEMENT 576 2171.75 80354.75 37.00
Subtotal (Total Children Is Unduplicated) 1327 3191.25 102352.25 32.07
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 1.00 48.50 48.50
EVAL-EVAL-DEVELOPMENTAL EVALUATION 48 47.75 2387.50 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 43 34.75 1737.50 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 4.00 300.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 0.50 37.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 3.50 262.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 28 32.00 2400.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 12 11.00 610.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 66 45.00 3375.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 2.00 150.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 49 41.50 3112.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 149 149.50 8297.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 165 178.00 13350.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 23 23.00 4255.00 185.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 3 3.00 315.00 105.00
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 1 1.00 160.00 160.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 8 8.00 388.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 10 10.00 485.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 17 17.00 824.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.00 97.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 36 36.00 1746.00 48.50
Subtotal (Total Children Is Unduplicated) 433 650.50 44339.25 68.16
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 51 85.25 4262.50 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 105 219.00 10950.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 87 202.00 5050.00 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 36 71.00 3550.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 39 80.00 2000.00 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 4 4.00 200.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 63 133.00 6650.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 58 120.00 3000.00 25.00
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 5 2.50 183.55 73.42
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 207 1468.25 73412.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 48 185.75 12608.71 67.88
OCCT-97530HM-OT SESSION BY OT ASST 1 3.00 162.96 54.32
PHY-97110-PT SESSION BY LICENSED PT 31 115.50 7840.14 67.88
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 1.00 50.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 77 328.53 22300.41 67.88
TRAN-TRAN-FAMILY TRANSPORTATION 357 373.00 2517.50 6.75
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 573 118770 59385.00 0.50
Subtotal (Total Children Is Unduplicated) 891 122162 214123.27 1.75
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Total 126003.53 360814.77 2.86
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Number of Children (Unduplicated) With at Least One Service 1501
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Center 04
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 3240 121458.53 211520.42 211520.41
D 16 356.00 1015.56 1071.24
S 0 0.00 0.00 0.00
H 14 33.50 1862.74 1862.74
T 0 0.00 0.00 0.00
5702 4155.50 146416.05 0.00
Other 0 0.00 0.00 0.00
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Total 8972 126003.53 360814.77 214454.39