CMS/EIP Fiscal Report Center: 05
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 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 303 123.00 4551.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 297 340.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 371 336.00 12432.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 782 2739.25 101343.00 37.00
Subtotal (Total Children Is Unduplicated) 788 3538.25 118326.00 33.44
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 8 8.50 433.25 50.97
EXIT-EXIT-TRANSITION ASSESSMENT 12 23.00 1150.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.00 75.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.00 150.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 5.00 375.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 5.00 375.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.00 111.00 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 14 15.50 860.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 51 67.00 4950.00 73.88
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 14 14.00 1050.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 22 27.58 1951.50 70.76
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 59 86.00 4773.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 15.50 1162.50 75.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 16 16.00 1164.48 72.78
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 10 10.00 501.50 50.15
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 3 3.00 145.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 11 11.00 560.00 50.91
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 10 10.00 485.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.00 97.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 18 18.00 900.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 17 17.00 824.50 48.50
Subtotal (Total Children Is Unduplicated) 185 359.08 22094.48 61.53
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 3.00 1154.10 384.70
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 70 64.75 3237.50 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 1 0.25 6.25 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 177 171.50 8575.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 8 2.50 62.50 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 66 30.75 1537.50 50.00
CONOP-CONOP-CONSULT, OT, PHONE 8 3.00 75.00 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 70 33.50 1675.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 120 66.25 3312.50 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 56 262.50 13125.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 272 1312.75 65637.50 50.00
HERN-EIIF_NM-EI HEARING SERVICES AFTER SHINE NONMED 1 3.00 150.00 50.00
INTR-INTR-INTERPRETER 6 35.25 1762.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 126 583.29 37389.43 64.10
OCCT-97530HM-OT SESSION BY OT ASST 5 21.75 1181.46 54.32
PHY-97110-PT SESSION BY LICENSED PT 143 591.33 39026.71 66.00
PHY-97110HM-PT SESSION BY PT ASST 1 2.00 108.64 54.32
SENS-V5264-EARMOLD 1 1.00 18.72 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 228 1072.87 72514.74 67.59
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 18 50.00 2716.00 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 4 9.00 118.80 13.20
TRAN-TRAN-FAMILY TRANSPORTATION 1 22.00 420.97 19.14
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 394 80183.0 40091.50 0.50
Subtotal (Total Children Is Unduplicated) 480 84525.2 293897.32 3.48
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Total 88422.57 434317.80 4.91
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Number of Children (Unduplicated) With at Least One Service 798
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Center 05
Flag Claims Units Chgs Paid
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R 32 32.00 1960.06 0.00
U 0 0.00 0.00 0.00
B 2315 1257.00 46509.00 0.00
P 2648 61958.12 121208.23 121208.23
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
8641 25175.45 264640.51 0.00
Other 0 0.00 0.00 0.00
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Total 13636 88422.57 434317.80 121208.23