CMS/EIP Fiscal Report Center: 05
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 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 429 1480.50 54769.25 36.99
Subtotal (Total Children Is Unduplicated) 690 2279.50 71752.25 31.48
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 7 7.50 383.25 51.10
EXIT-EXIT-TRANSITION ASSESSMENT 12 23.00 1150.00 50.00
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 1 1.00 75.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 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 15 14.50 1087.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 4.00 300.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 3.08 114.00 37.01
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 47 70.00 3885.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 11 14.50 1087.50 75.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 1 1.00 72.78 72.78
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 1 1.00 50.15 50.15
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 5 5.00 242.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 1.00 50.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 2 2.00 97.00 48.50
Subtotal (Total Children Is Unduplicated) 105 168.08 9790.93 58.25
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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 47 193.50 9675.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 194 1012.00 50600.00 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 37 151.79 8099.21 53.36
PHY-97110-PT SESSION BY LICENSED PT 21 74.83 3966.69 53.01
SENS-V5264-EARMOLD 1 1.00 18.72 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 68 323.62 21655.65 66.92
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 4 14.50 787.64 54.32
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) 441 82390.0 156863.23 1.90
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Total 84837.57 238406.41 2.81
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Number of Children (Unduplicated) With at Least One Service 743
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Center 05
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 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
4871 22879.45 117198.18 0.00
Other 0 0.00 0.00 0.00
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Total 7519 84837.57 238406.41 121208.23