CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2008 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 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 629 2230.25 82519.25 37.00
Subtotal (Total Children Is Unduplicated) 1300 3155.25 100390.25 31.82
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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 14 8.50 637.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 3.00 225.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 8 4.50 337.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 41 41.50 3112.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 28 25.00 1387.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 55 34.50 2587.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 9 7.00 525.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 51 38.50 2887.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 146 135.00 7492.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 145 139.00 10425.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 8 8.00 1480.00 185.00
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 1 1.00 160.00 160.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 6 6.00 291.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 15 16.00 776.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 4 4.00 194.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 6 6.00 291.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 25 25.00 1212.50 48.50
Subtotal (Total Children Is Unduplicated) 439 607.50 39272.00 64.65
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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
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 169 1020.00 51000.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 45 144.42 9803.14 67.88
PHY-97110-PT SESSION BY LICENSED PT 20 90.50 6143.14 67.88
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 47 244.00 16562.72 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 1 3.00 39.60 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) 851 98051.4 157228.10 1.60
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Total 101814.17 296890.35 2.92
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Number of Children (Unduplicated) With at Least One Service 1500
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Center 04
Flag Claims Units Chgs Paid
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R 15 15.50 573.50 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 2250 97448.92 151868.68 152020.21
D 126 325.25 6021.89 6021.89
S 0 0.00 0.00 0.00
H 27 78.50 4255.78 4357.60
T 0 0.00 0.00 0.00
5131 3946.00 134170.50 0.00
Other 0 0.00 0.00 0.00
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Total 7549 101814.17 296890.35 162399.70