CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/17/2009 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 801 456.00 16872.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 440 442.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 44 27.00 999.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1611 5962.25 220603.25 37.00
Subtotal (Total Children Is Unduplicated) 1637 6887.25 238474.25 34.63
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 66 66.00 3300.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 40 39.00 1950.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 16 10.00 750.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 3.50 262.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 9 5.00 375.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 43 50.50 3787.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 47 43.50 2414.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 92 56.50 4237.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 11 8.50 637.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 79 59.00 4425.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 246 233.00 12931.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 165 168.50 12637.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 125 125.00 23125.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 3 3.00 825.00 275.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 46 46.00 4830.00 105.00
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 2 2.00 320.00 160.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 8 8.00 388.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 25 26.00 1261.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 10 10.00 485.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 7 7.00 339.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 38 38.00 1843.00 48.50
Subtotal (Total Children Is Unduplicated) 534 1008.00 81124.75 80.48
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 39 50.00 2500.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 89 152.00 7600.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 55 101.00 2525.00 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 25 45.00 2250.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 20 36.00 900.00 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 8 10.50 525.00 50.00
CONPP-CONPP-CONSULT, PT, PHONE 1 1.00 25.00 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 61 94.00 4700.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 39 65.00 1625.00 25.00
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 106 3818.00 95450.00 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 55 2134.00 53350.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 523 3549.00 177450.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 105 498.20 33787.26 67.82
OCCT-97530HM-OT SESSION BY OT ASST 1 1.00 54.32 54.32
PHY-97110-PT SESSION BY LICENSED PT 99 484.50 32887.86 67.88
PHY-97110HM-PT SESSION BY PT ASST 1 1.50 81.48 54.32
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 1.00 50.00 50.00
SIC-SIC-SPECIAL INSTRUCTION CONSULTATION 1 5.00 250.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 149 680.00 46158.40 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 2 4.50 59.40 13.20
TRAN-TRAN-FAMILY TRANSPORTATION 380 396.00 2933.00 7.41
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 530 95593.0 47796.50 0.50
Subtotal (Total Children Is Unduplicated) 1002 107720 512958.22 4.76
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Total 115615.45 832557.22 7.20
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Number of Children (Unduplicated) With at Least One Service 1722
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Center 04
Flag Claims Units Chgs Paid
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R 27 38.00 1406.00 0.00
U 0 0.00 0.00 0.00
B 2983 2887.25 111722.75 0.00
P 3371 98460.67 192017.58 191952.79
D 128 327.00 6099.64 6049.64
S 0 0.00 0.00 0.00
H 791 2529.28 129861.24 129771.38
T 0 0.00 0.00 0.00
6313 11373.25 391450.01 0.00
Other 0 0.00 0.00 0.00
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Total 13613 115615.45 832557.22 327773.81