CMS/EIP Fiscal Report Center: 52
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 441 238.50 8824.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 351 443.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 308 232.50 8602.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 774 2069.25 75766.75 36.62
TCON-TCON-TRANSITION CONFERENCE 56 57.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 790 3040.25 93193.75 30.65
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-TRANSITION ASSESSMENT 10 12.50 625.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 4.50 337.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 3.00 225.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.50 112.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 6.00 333.00 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 38 40.00 1997.00 49.93
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 113 158.00 9930.50 62.85
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 8.00 467.50 58.44
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 44 52.00 3226.50 62.05
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 100 151.50 8408.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 22 34.00 2550.00 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 32 32.00 1552.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 6 6.00 276.44 46.07
PSTH-97001-EVAL BY LICENSED PT, INITIAL 16 17.00 824.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 12 12.00 600.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 34 34.00 1649.00 48.50
Subtotal (Total Children Is Unduplicated) 255 573.00 33163.19 57.88
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 33 34.25 1712.50 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 1 0.50 12.50 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 16 11.25 562.50 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 2 0.50 12.50 25.00
CONOP-CONOP-CONSULT, OT, PHONE 1 0.25 6.25 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 0.25 12.50 50.00
CONPP-CONPP-CONSULT, PT, PHONE 3 1.25 31.25 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 9 6.50 325.00 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 41 194.00 5880.00 30.31
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 151 826.75 40037.50 48.43
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 1 6.00 300.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 95 649.50 44088.06 67.88
PHY-97110-PT SESSION BY LICENSED PT 131 635.00 43142.16 67.94
PHY-97110HM-PT SESSION BY PT ASST 3 6.25 346.28 55.40
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 1.50 75.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 288 1495.50 101514.54 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 500 92950.0 46475.00 0.50
Subtotal (Total Children Is Unduplicated) 542 96819.3 284533.54 2.94
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Total 100432.50 410890.48 4.09
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Number of Children (Unduplicated) With at Least One Service 803
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Center 52
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 1848 1144.00 49087.67 0.00
P 143 100.00 2812.76 2664.00
D 0 0.00 0.00 0.00
S 1 0.25 9.25 0.00
H 79 124.25 7962.08 0.00
T 1016 41501.96 56509.88 56403.38
6434 57562.04 294508.84 0.00
Other 0 0.00 0.00 0.00
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Total 9521 100432.50 410890.48 59067.38