CMS/EIP Fiscal Report Center: 57
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Payclass Filters:GR
Eligibility Filter:Part C (excluding not eligible)
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 315 250.00 9250.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 465 688.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 229 175.50 6493.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 597 2127.00 78547.00 36.93
TCON-TCON-TRANSITION CONFERENCE 3 3.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 896 3243.50 94290.50 29.07
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Screening, Eval, and Assessment,Class #02
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 4 4.00 200.00 50.00
EVAL-EVAL-DEVELOPMENTAL EVALUATION 4 4.00 200.00 50.00
FANE-FANE-FAMILY INTERVIEW BY COMMUNITY PROVIDER 7 7.00 210.00 30.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 3.00 225.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 3.00 166.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 85 85.00 6348.50 74.69
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 25 25.00 1875.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 127 127.00 7048.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 16 16.00 1175.00 73.44
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 19 19.00 921.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 11 11.00 533.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 9 9.00 436.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 10 10.00 485.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 4 4.00 200.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 59 59.00 2861.50 48.50
Subtotal (Total Children Is Unduplicated) 213 386.00 22886.50 59.29
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 14 15.00 750.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 205 328.50 16375.00 49.85
CONIP-CONIP-CONSULT, ITDS, PHONE 278 546.75 13656.25 24.98
CONOF-CONOF-CONSULT, OT, FACE TO FACE 7 11.25 562.50 50.00
CONOP-CONOP-CONSULT, OT, PHONE 3 3.50 87.50 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 3 2.50 125.00 50.00
CONPP-CONPP-CONSULT, PT, PHONE 5 7.00 175.00 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 211 345.50 17212.50 49.82
CONSP-CONSP-CONSULT, SLP, PHONE 266 530.75 13118.75 24.72
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 7 30.00 1050.00 35.00
ECE-ECE-EARLY CHILDHOOD EDUCATION 1 28.00 252.00 9.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 3 72.00 1510.00 20.97
EIIF-90801-PSYCHIATRIC DIAG INTERVIEW 1 5.00 250.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 372 3167.50 151727.50 47.90
OCCT-97530-OT SESSION BY LICENSED OT 33 109.25 7405.89 67.79
PHY-97110-PT SESSION BY LICENSED PT 42 125.75 8505.91 67.64
PHY-97110HM-PT SESSION BY PT ASST 1 1.50 27.22 18.15
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 5 8.00 400.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 102 420.50 27968.84 66.51
SPL-92508-GROUP SPL SESSION PER CHILD 1 0.50 6.60 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 668 130692 67035.80 0.51
Subtotal (Total Children Is Unduplicated) 749 136451 328202.26 2.41
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Total 140080.25 445379.26 3.18
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Number of Children (Unduplicated) With at Least One Service 1127
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Center 57
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 1 75.00 37.50 37.50
D 0 0.00 0.00 0.00
S 120 2368.00 7244.54 7244.54
H 0 0.00 0.00 0.00
T 5103 134098.75 327424.94 328585.13
3699 3538.50 110672.28 701.82
Other 0 0.00 0.00 0.00
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Total 8923 140080.25 445379.26 336568.99