CMS/EIP Fiscal Report Center: 52
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 394 210.50 7779.25 36.96
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 388 480.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 347 309.25 11433.00 36.97
TCM-T1017TL-TARGETED CASE MANAGEMENT 720 2187.00 80188.25 36.67
TCON-TCON-TRANSITION CONFERENCE 61 62.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 734 3248.75 99400.50 30.60
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-TRANSITION ASSESSMENT 6 6.50 325.00 50.00
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 3 3.00 150.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 9.50 534.50 56.26
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 2.00 97.00 48.50
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 3.00 145.50 48.50
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.00 225.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 5.50 299.75 54.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 58 65.50 3264.50 49.84
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 167 232.00 15093.50 65.06
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 16 19.50 968.00 49.64
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 39 46.49 2846.50 61.23
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 141 211.50 11723.60 55.43
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 23 34.50 2695.00 78.12
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 28.00 1358.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 3 3.00 145.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 14 14.00 679.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 6 6.00 300.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 31 32.00 1503.50 46.98
Subtotal (Total Children Is Unduplicated) 305 732.99 42741.85 58.31
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.00 1100.00 550.00
AUD-HA_FUP-AUDIOLOGY SERVICES 2 2.00 100.00 50.00
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 38 49.00 2450.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 17 12.00 600.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 3 0.75 18.75 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 2.00 100.00 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 4 3.50 175.00 50.00
CONPP-CONPP-CONSULT, PT, PHONE 3 1.25 31.25 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 8 6.75 337.50 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 4 1.75 43.75 25.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 56 332.50 12075.00 36.32
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 139 747.25 35720.00 47.80
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 1 9.00 450.00 50.00
INTR-INTR-INTERPRETER 1 2.00 100.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 98 670.50 45757.58 68.24
PHY-97110-PT SESSION BY LICENSED PT 120 632.00 43364.17 68.61
PHY-97110HM-PT SESSION BY PT ASST 3 6.75 366.66 54.32
SENS-V5264-EARMOLD 1 2.00 37.44 18.72
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 2.50 125.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 288 1584.02 107893.02 68.11
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.00 13.20 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 533 105969 52975.50 0.50
Subtotal (Total Children Is Unduplicated) 573 110040 303833.82 2.76
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Total 114021.26 445976.17 3.91
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Number of Children (Unduplicated) With at Least One Service 762
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Center 52
Flag Claims Units Chgs Paid
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R 8 8.00 534.34 0.00
U 0 0.00 0.00 0.00
B 1352 851.75 35436.17 9.25
P 856 574.59 27069.31 27069.31
D 0 0.00 0.00 0.00
S 3 9.50 351.50 0.00
H 95 173.75 10872.77 0.00
T 0 0.00 0.00 0.00
7638 112403.67 371712.08 0.00
Other 0 0.00 0.00 0.00
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Total 9952 114021.26 445976.17 27078.56