CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 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 1985 2140.25 79189.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 1715 1802.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 269 172.50 6346.50 36.79
TCM-T1017TL-TARGETED CASE MANAGEMENT 1507 10159.0 375873.75 37.00
Subtotal (Total Children Is Unduplicated) 2717 14273.8 461409.50 32.33
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 3 4.00 194.00 48.50
EVAL-EVAL-DEVELOPMENTAL EVALUATION 221 223.25 11162.50 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 147 140.25 7012.50 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 45 37.00 2775.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 18 16.50 1237.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 16 12.00 900.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 139 180.50 13537.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 134 144.00 7992.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 318 252.50 18937.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 16 14.00 1050.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 168 140.00 10500.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 760 779.00 43234.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 707 784.00 58800.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 153 154.00 28490.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 2 2.00 550.00 275.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 35 35.00 3675.00 105.00
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 3 3.00 480.00 160.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 19 20.00 970.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 39 40.92 1984.62 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 29 30.00 1455.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 17 17.00 824.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 93 100.00 4850.00 48.50
Subtotal (Total Children Is Unduplicated) 1647 3128.92 220612.12 70.51
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 129 260.25 13012.50 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 10 6.00 150.00 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 187 697.50 34875.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 173 799.50 19987.50 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 71 223.00 11150.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 78 290.00 7250.00 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 12 24.50 1225.00 50.00
CONPP-CONPP-CONSULT, PT, PHONE 2 2.00 50.00 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 129 434.50 21725.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 125 509.00 12725.00 25.00
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 10 6.00 440.52 73.42
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 499 5456.25 272812.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 88 657.32 44530.82 67.75
OCCT-97530HM-OT SESSION BY OT ASST 2 3.50 190.12 54.32
PHY-97110-PT SESSION BY LICENSED PT 52 330.00 22349.60 67.73
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 9 23.00 1150.00 50.00
SIC-SIC-SPECIAL INSTRUCTION CONSULTATION 1 5.00 250.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 128 927.07 62929.31 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 1 3.00 39.60 13.20
TRAN-TRAN-FAMILY TRANSPORTATION 1395 1565.00 10830.00 6.92
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 958 462598 231298.50 0.50
Subtotal (Total Children Is Unduplicated) 1918 474820 768970.97 1.62
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Total 492223.06 1450992.59 2.95
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Number of Children (Unduplicated) With at Least One Service 2820
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Center 04
Flag Claims Units Chgs Paid
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R 19 17.75 656.75 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 11673 471396.06 750363.59 750521.95
D 1044 2789.00 59798.06 30716.24
S 0 0.00 0.00 0.00
H 51 142.00 7707.92 7809.74
T 0 0.00 0.00 0.00
23443 17878.25 632466.27 0.00
Other 0 0.00 0.00 0.00
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Total 36230 492223.06 1450992.59 789047.93